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The Insurance maintenance screen allows you to add and edit third party accounts. By adding a particular insurance provider to your records, you can make that provider an option to be used in the Script Filling screen. You can find the Insurance maintenance screen by clicking on the Maintenance menu item and selecting the Insurances option.



How Do I Add a New Insurance Provider?

How Do I Edit Insurance Information?

How Do I Attach Insurance to a Patient's Account?

How Do I Add Specific Overrides?



How Do I Add a New Insurance Provider?

To create a new third party account:


1.Click on the Maintenance menu item.

2.Select Insurances. The Insurance maintenance screen will open.

3.Click on the Create New Insurance option.

4.Enter the Name of the insurance provider.

5.Enter the provider's Short Code (e.g., BCBS).

6.Enter the insurance company's Bank Identification Number in the BIN field.

7.Enter the insurance company's Processor Control Number in the PCN field.

8.In the SVCN field, enter the Software Vendor Certification Number.

9.Choose an Insurance Type (Normal, Medicaid, etc.).

10.Click on the drop-down arrows in the Doctor Number and User ID Qualifier fields. Select the correct qualifier types (e.g., NPI Number, State License).

11.Enter a Pharmacy ID and select the appropriate Pharmacy ID Qualifier type (e.g., NPI, State License).

12.Enter the Address for this insurance company.

13.Enter the appropriate Phone, Fax, and Website information.

14.If you are using an Insurance Formulary System, search for the correct formulary in this field.


Insurance Formulary Systems may be useful if you are self-insuring. These systems allow you to set up copay amounts and coverage details for a third party. If you are handling insurance claims in-house, you will want to set up a third party that uses your specific Formulary and Copay settings.


15.If this insurance provider supports multi-claim processing, mark the Multi Claim checkbox.

16.If the insurance is only to be used to cover copays, mark the Copay Only checkbox.

17.If the Drug Override option is set, when a script's drug has a pricing override, the drug's override pricing table will be used rather than the insurance pricing table. (If this option is not selected, the insurance's pricing will trump any drug override.)

18.You can also enter the correct Place of Service.

19.To activate this provider for use in your pharmacy system, mark the Active checkbox.

20.When you have entered the needed information, click on the Save button.



How Do I Edit Insurance Information?


1.Click on the Maintenance menu item.

2.Select Insurances. The Insurance maintenance screen will open.

3.Start typing in the Search Insurance field to find the correct insurance provider. You can search by the insurance's name, BIN, or PCN. (If the search field is not shown, click on the magnifying glass icon to display it.)

4.Select the fields that need to be changed and enter the new information.

5.Once you have finished making changes, click Save.



How Do I Attach Insurance to a Patient's Account?

You can add an insurance account to a patient's record, tying a particular insurance provider to the patient and adding specific account information. To add insurance for a patient, follow these instructions:


1.Click on the Maintenance menu item.

2.Select Patients.

3.Enter part of the patient's name (or Account Number, etc.) into the Search Patient field to begin a search.

4.After you have selected the patient, click on the Insurances tab.

5.Click on the Add New option.

6.If this third party will be used when filling scripts for the patient, make sure the Active checkbox is marked.

7.Select the correct insurance provider in the Insurance field.

8.Enter a number in the Billing Order field. If you have multiple insurances attached to this patient, when a user searches for the correct insurance for the patient in the Script Filling screen, each insurance will be listed in their chosen Billing Order in the search list (Billing Order 1 on top, followed by Billing Order 2, etc.).

9.Choose the patient's Relation to the insured (e.g., Cardholder, Spouse).

10.Enter the Card Holder ID and any other necessary identification (Plan Number, Group Number, or Other Number).


The Other Number field is used for a specific ID Qualifier type. In the ID Qualifier field, you can choose which type of identifier will be used for the patient (SSN, Driver's License, etc.). If you select the "Other" option, you will need to enter a specific number in the Other Number field.


11.Choose the correct type of Patient Residence (Correctional Institution, Group Home, etc.).

12.Choose the correct ID Qualifier for this insurance company. This is the type of identification that the insurer will use to identify the patient.

13.Enter the name of the Primary insured (Last, First, and Middle Name).

14.Choose an Expiration Date (the day the insurance will no longer be in effect) and an Effective Date (the day insurance coverage begins).

15.If the patient is Eligible for this insurance, mark the Eligible checkbox.

16.If necessary, you can enter the patient's Date of Birth. (This may be useful if the insurance provider has the wrong birthday listed for the patient.) If no date is entered here, the insurance will use the patient's Date of Birth as it is listed under the Record Info tab.

17.If this is the patient's default insurance, mark the Default checkbox. (There is a setting in the Options screen to choose how a patient's insurance is selected in the Script Filling screen. If you choose the "Default Insurance" option, this insurance will be entered automatically when you begin filling a script for this patient.) You should only make one insurance the patient's default. Otherwise, ProPharm may select the wrong option.


The patient's Default Insurance will be shown in bold when searching for an insurance in the Script Filling screen.


18.Enter any needed account information in the following fields: Place of Service, Coverage, Special Coverage, Person Code, and Home Plan. (Specific information for these fields may be required by the provider.)

19.Click Save.



How Do I Add Specific Overrides?

If an insurance needs a specific value to be submitted for a field, you can set up Overrides to handle some of those situations. To add an override:


1.Click on the Maintenance menu item.

2.Select Insurances. The Insurance maintenance screen will open.

3.Start typing in the Search Insurance field to find the correct insurance provider.

4.Choose a provider and then click on the Overrides tab. If there are any overrides already set up for this insurance, they should appear on the screen.

5.Click on the Add Override button. A list of override types will appear. (e.g., "Remove NR, NP and NQ Fields." This override can be used if the insurance provider cannot handle these fields.)  

6.Locate the needed option and click Select Override. (You can select multiple overrides if needed.)

7.Click Close. The new override type should appear in your list.


See Also

Other Pharmacies


Insurance Formulary System