Table of Contents

Step 6: Configuring benefits for your product template

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.

Procedure

  1. On the Configure groupers and benefits page, click the Configure item icon to the right of PRO Physical Therapy.
  2. Click the tab to the left of PPO In-network to open it.
  3. Click Edit.
  4. In the Configure or modify benefit-specific coverage dialog box, select the Limit check box and click OK.
  5. In the Limit section on the Configure groupers and benefits page, clear the Limit not applicable? check box.
  6. In the Select Limit type list, select Benefit limit and then follow these steps:
    1. In the Limit name field, enter Physical therapy.
    2. In the Limit type field, select Benefit Limit.
    3. In the Benefit Limit field, enter 30.
    4. In the Select frequency list, select Calendar year.
    5. For this tutorial, ignore the optional Combined Across Networks check box.
    6. In the Calculation Method list, select Per Unit.
    7. For this tutorial, ignore the optional Step-down instructions check box.
  7. Click Save.
    Benefit limit
    Benefit limit
  8. Click Submit.
  9. On the Configure groupers and benefits page, click Mark all as complete.
  10. Click Continue.

    What to do next

    Set the default benefit category. See Step 7: Setting the default benefit categoriesfor your product template.

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