Benefit Parameters

Parameters tracked by benefit line include filing limits; pre-existing condition and general waiting periods; reinsurance limits; exclusions by diagnosis, service type, or procedure code; deductibles by primary care, in-network, and out-of-network, either combined or separated; plan maximums; and fourth-quarter carryover options.

Benefit Accumulators

Deductibles and maximums can be accumulated for a contract or a calendar year for per-charge, annual, and lifetime limits. Deductibles may be applied to an individual patient, to an entire family with an aggregate dollar amount ceiling, or to a family with a ceiling defined by the number of family members, each of which must reach an annual dollar amount.

Limits

There are up to 99,999 locations, 999 divisions per location, 99 classes (key management, line management, salaried, hourly, etc) per division, and 99 lines of benefits per class. Each benefit line may be an HMO or PPO plan(e.g. PlanA, PlanB), a self-funded benefit (e.g. medical, dental, vision, pharmacy, STD, LTD), or a section 125 benefit.

Provider Assignments

An unlimited number of provider groups and networks can be attached to a benefit line. When a subscriber or member enrolls for a particular benefit, only those providers within a group or network attached to that line are listed for selection.

Diagnosis and Service Tables

A user defined table of diagnosis codes and ranges of diagnosis codes can be attached to each benefit line. This table is used to exclude selected diagnoses from coverage and to assign waiting periods by diagnosis. Services can be limited to a certain age range, sex, or provider specialty.

Easy Renewals/Updates

Benefit profiles and attached tables can be copied from a prior period, from a test environment, or from a previously entered class and then changed as appropriate. This minimizes the work necessary to update benefit profiles and plans.