You can modify the coverage for a benefit or grouper that was previously included as part of a benefit set for a specific network. For example, you can add the values for the benefit-specific coverage such as copayment or coinsurance and include deductible or out-of-pocket amounts. In addition, you can configure the order of cost shares that is used in claim adjudication. You can assign cost shares for specific conditions or assign limits to a benefit. For example, you can limit physical therapy sessions to 30 visits per year.
For this tutorial, you are only going to add a visit limit for physical therapy sessions.
Before you begin
Ensure that you configured the cost shares at the network level. See Step 5: Configuring network cost shares for your product template.
- On the Configure groupers and benefits page, click the Configure item icon to the right of PRO Physical Therapy.
- Click the tab to the left of PPO In-network to open it.
- Click .
- In the Configure or modify benefit-specific coverage dialog box, select the Limit check box and click .
- In the Limit section on the Configure groupers and benefits page, clear the Limit not applicable? check box.
- In the Select Limit type list, select Benefit limit and then follow these steps:
- In the Limit name field, enter Physical therapy.
- In the Limit type field, select Benefit Limit.
- In the Benefit Limit field, enter 30.
- In the Select frequency list, select Calendar year.
- For this tutorial, ignore the optional Combined Across Networks check box.
- In the Calculation Method list, select Per Unit.
- For this tutorial, ignore the optional Step-down instructions check box.
- Click Save.
- Click .
- On the Configure groupers and benefits page, click Mark all as complete.
What to do next
Set the default benefit category. See Step 7: Setting the default benefit categoriesfor your product template..