Set up an HMO

Hospitals outside the US bill HMOs. Everything an HMO has agreed with you is set up in one place, the Insurance page, so a claim can be priced and split the way the HMO will adjudicate it.

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What you’re looking at

Everything opens in a side panel (a bottom sheet on a phone). The Add button at the top of the page adds an insurer, plan, service price, medicine price or item coverage from any tab. Empty state. A hospital with no insurer yet sees Add an insurer first on Billing setup — add one on Companies, then come back.

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Add the insurer

To change an insurer later, open its row menu and choose Edit. Turn Active off to stop offering it on new claims while keeping its history.

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Add a plan and say what it covers

On Plans, select Add Plan.

• Patient pays (%) — the share of each bill the patient pays. The insurer covers the rest. Leave it empty if you have not agreed one.
• Plan limit per enrollee — the most the plan will pay for one member.
• VAT on the plan — recorded for the insurer’s records. Tax, additional charges and flat-rate fees always stay with the patient; they are never billed to the insurer.
• Waiting period (days), Pre-authorization required, Network, Plan code and Plan type.
• Covers dependants and Most dependants covered.
• Valid at every provider and The insurer’s plan ID.

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Benefits

A benefit is a rule for one kind of care under a plan. Save the plan, then use Add benefit in the same panel. Name it (for example Dental or Maternity), choose what it Covers and its Claim category, say whether it is Covered, what the patient pays, the limit (an amount or a number of times), the waiting period in days and who it is For. Remove asks first; claims already filed are not changed.

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Set the price list

On Pricing, select Add Service or Add Medicine.

• Tariff code and the item’s name. A bill line is priced from this row when its code, or failing that its name, matches.
• Care type and Care item group the price (for example Laboratory, then Haematology).
• Price is the insurer’s agreed price for one unit.
• Tariff band, Valid from and Valid until say which version of the list this price belongs to. The same code can appear again with another band or start date; the version in force on the day is the one used.
• Active off keeps the price but never uses it.

To load a whole list, select Import CSV, choose the insurer and the file. Download the template shows the columns. Prices with the same code, band and start date are updated, not duplicated, and the panel lists the first rows it could not import.

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Add employer groups and tariff terms

On Billing setup, choose the insurer. Add group takes the company’s name, its group code and policy number, and its status (Active, Inactive or Terminated). Removing a group does not remove its members’ cover; they stop being linked to the group. Tariff terms sets the band and the dates for every price in one list at once: choose Services or Medicines, enter the Tariff band and Valid from / Valid until, and select Apply to the list.

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How a bill is priced

When you bill an HMO for a sale (Bill HMO), each item goes on the claim at the insurer’s agreed price where there is one, and at your own price where there is not. The patient’s share is worked out on that agreed price. If the agreed price is lower than yours, the difference is not billed to anyone. An agreed price higher than your own is not used: the claim stays at your price. When you start a claim from an invoice, ClinikEHR also uses the insurer’s agreed price and tells you which lines used your price. See File and track claims.

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Who can do this

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Check it worked

• The insurer is on Companies, with its codes.
• A plan row shows Patient pays as a percentage.
• A price row shows its Tariff band and dates.
• Leave the page and come back: everything is still there.

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Common issues