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Insurance Eligibility
Item Eligibility
Item Insurance Eligibility defines which healthcare services and items are covered under specific insurance plans.
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Home>Insurance>Eligibility>Item Insurance Eligibility
| Field | Description |
|---|---|
| Item | The healthcare service or product |
| Insurance Payor | Which payor covers this item |
| Coverage Percentage | What percentage the insurance covers (e.g., 80%) |
| Maximum Amount | Cap on the coverage amount |
| Pre-authorization Required | Whether prior approval is needed |
Coverage Plans (Eligibility Plans)
Insurance Payor Eligibility Plans group eligibility rules into named plans
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Home>Insurance>Eligibility>Insurance Payor Eligibility Plan
| Field | Description |
|---|---|
| Plan Name | e.g., "Gold Plan", "Silver Plan", "Basic Coverage" |
| Insurance Payor | The insurance company offering this plan |
| Covered Items | List of items/services covered under this plan |
| Coverage Details | Percentage, limits, and conditions for each item |
Example: Gold Plan Coverage
| Service | Coverage % | Max Amount | Pre-auth |
|---|---|---|---|
| OPD Consultation | 100% | Rs. 1,000 | No |
| Lab Tests | 100% | Rs. 10,000 | No |
| Minor Procedures | 80% | Rs. 25,000 | No |
| Major Surgery | 80% | Rs. 5,00,000 | Yes |
| Room Charges | 100% | Rs. 5,000/day | No |