Table of Contents

Configuring the FAC-Urgent Care benefit

The FAC-Urgent Care benefit includes the coverage for a visit to an urgent care facility that is part of a hospital. For example, if you experienced a fall, you would use this benefit to cover the services such as X-rays that the urgent care facility provides.

Before you begin

Before you configure this benefit, read the description and perform the required tasks that are listed in Benefits.

Procedure

  1. In the header of Dev Studio, click Launch web interface > Product Development.
  2. In the left navigation panel of your work space, click New > Benefit.
  3. Click New.
  4. In the Name field, enter FAC-Urgent Care.
  5. In the Effective date field, enter 1/1/2019, and in the End date field, enter 12/31/9999.
    This end date means that the benefit might be in use indefinitely. By manually entering 9999 for the year, you do not have to continually update the end date.
  6. In the Insurance line list, select Medical.
  7. In the Line of business list, select Commercial.
  8. In the Benefit category list, select Urgent-Services.
  9. Click Add Purpose and Alias names. In the Purpose field, click Sales and in the Name field, enter a meaningful name for the benefit that individuals in the business area understand, for example, Urgent Care.
    These fields are optional.
  10. For this tutorial, ignore the optional Client benefit id and Description fields.
  11. Ensure that the Is wellness benefit check box is not selected because this benefit is not a wellness benefit.
    FAC-Urgent Care benefit
  12. Click Continue.
  13. In the Define Mapping step of the wizard, define the conditions (codes) to describe the benefit which then is understood by a claims adjudication system.
    1. In the Definition list, select Bill Type Groups and click Add definition.
    2. Click Add Bill Type Group.
    3. In the Code group field, enter BT002 and select it from the list.
      The Description field displays Bill Type Group-Outpatient.
    4. Click Add Service Group.
    5. In the Code group field, enter RV040 and select it from the list.
      The Description field displays Urgent care.
  14. For this tutorial, ignore the optional Override section because it does not apply.
    If you are integrated with a downstream processing claim system that requires an indicator to advise when one benefit precedes or overrides another, you select this check box. The systems use this benefit on all claim lines so that the member pays only for the cost shares associated with this benefit.
  15. Click Generate Description to list the overrides to the benefit.
    Groups for the FAC-Urgent Care Facility benefit
    Groups for the FAC-Urgent Care Facility benefit

You can click the Show Detail icon next to the Description field to view the details of the code group.

  1. Click Continue.
  2. In the Enter notes step of the wizard, click the SBC Benefits Description tab, and enter FAC-Urgent Care benefit is required. Then click Continue.
  3. In the Review benefit step, review the benefit and then click Finish.
  4. Because you have manager credentials, approve the benefit entity by following these steps:
    1. Click Actions > Approve and hold at the top right.
      By selecting Approve and hold instead of Approve, the entity remains in the current stage, but is available for use in other tasks. To advance the entity to the next stage, click Approve.
    2. In the Approve section, click Submit.

What to do next

Configure a grouper with benefits. See Configuring a benefit grouper.

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