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Former Member

Insurance Approval Amount in billing IS-H

Dear ISH Billing Experts,

I have a scenario in billing with 2 bills, one is for insurance and another for self payer.

when patient billing happens in the hospital, insurance team will be contacted and approved amount on the  patient. insurance card will be billed to the insurance company and remaing will be billed to the patient.

My Scenario:

Gross Amount Billed - 600

During billing following happened:(Based on the services used)

Test Billing (Based on internal discounts on services)

Insurance Company  - 400

Patient Share            - 200

However, when insurance company was contacted, they approved only 300

Insurance Appvroved amount - 300

So now again, when billing happen

Actual Billing after Insurance Approval:

Insurance Company  - 400 - 300(Approved Amount) = 100(Balance Amount) 

Patient Share            - 200 + 100 (Balance Amount)

So insurance billed was only 300 and patient billed was 300.

During billing my scenario is, when i go to Ins. Invoice is should see 300.

When i go to Patient Invoice - 100(balance amont from ins bill) should get equally divided into all the line items.

For acheiving this, we have created a Static Condition Type - zdis and it should divide 100 in all the line items...of the patient invoice, whereas we have another condition type for this zact which will store 300(zact) as actual invoice amount and -100(zdis) in insurance invoice.

In patient invoice, 200(zact) and +100(zdis).

Can anyone let me know, the solution to achieve this either by vofm routines or exits.



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1 Answer

  • Oct 06, 2013 at 03:23 PM

    Hi, what billing engine are you using? Insurance verification or payment distribution?

    With Best regards


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    • Former Member Matias Montes de Oca

      Dear Matias,

      I am having a similar scenario, we are using insurance verification billing engine, could you please let me know how to implement group condition and transfer the excess amount when insurance approval amount is reached to patient account.


      Rajesh Y