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Configure Care Limit Type
To use Pharmacy Benefits Verification, you must define care limit types such as co-pay, co-insurance, and many more to determine the pharmacy benefits that are available to a patient.
Required Editions
| Available in: Lightning Experience |
| Available in: Enterprise and Unlimited Editions with Life Sciences Cloud or Health Cloud |
| User Permissions Needed | |
|---|---|
| To create a care limit type: | Customize Application |
The pharmacy benefits that we see in the verification response have to be set up as new care limit types
| Name | Limit Type | Description |
|---|---|---|
| CoPay | copay | Amount to be collected from the policyholder to satisfy a per prescription copay. |
| CoInsurance | coinsurance | Amount to be collected from a policyholder to satisfy a per prescription coinsurance. |
| Deductibles | deductibles | Amount to be collected from the policyholder before the insurance starts covering costs for covered services. |
| DeductiblesApplied | deductiblesapplied | Amount of out-of-pocket expenses to be counted towards satisfying the annual deductible, which contributes to reaching the threshold for insurance coverage to begin. |
| DeductiblesMet | deductiblesmet | Represents the full deductible amount that the policyholder has paid, after which the insurance begins to share in the cost of covered services as per the terms of the plan. |
| InfusionCoInsurance | infusioncoinsurance | Amount to be collected from the policyholder to satisfy a per infusion therapy coinsurance. |
| InfusionCoPay | infusioncopay | Amount to be collected from the policyholder to satisfy a per infusion therapy copay. |
| Ltm | ltm | Represents the maximum amount an insurance policy will pay for covered services over the lifetime of the policyholder. After this limit is reached, the policyholder is responsible for all additional costs. |
| OopMax | oopmax | Represents the maximum amount a policyholder is required to pay out-of-pocket for covered healthcare services in a plan year. After this limit is reached, the insurance company covers 100% of the costs for covered services for the remainder of the plan year. |
| OopMaxMet | oopmaxmet | Represents the maximum amount a policyholder has paid from out-of-pocket for covered healthcare services in a plan year. After this stage all additional costs for covered services are now fully covered by the insurance for the rest of the plan year. |
| OutOfPocketApplied | outofpocketapplied | Represents the maximum amount a policyholder is required to pay out-of-pocket for covered healthcare services in a plan year. After this limit is reached, the insurance company covers 100% of the costs for covered services for the remainder of the plan year. |
| RemainingLtm | remainingltm | Represents the amount of coverage still available under an insurance policy for covered services over the lifetime of the policyholder, after deductibles and previous claims have been accounted for. |
| Total | total | Represents the amount of coverage provided by the insurance policy for all covered services within a specified period or for the policyholder’s lifetime. |
- From Setup, in the Quick Find box, enter Care Limit Type, and then under Benefits Verification, select Care Limit Type.
- Click New Care Limit Type.
- Enter the label.
- Enter CoPay as the name and copay as the limit type.
-
In Metric Type, select the unit by which the benefit limit is measured.
Note Select Money if the limit is on the amount that is billed. If the limit can’t be measured in terms of money, time, or amount, select Text so that the user can type a description. -
Repeat the steps for all the care limit types listed in the table.
Note In the limit type field, save all the care limit types exactly as is. These limit types are required to initiate the verification request and to view the current benefits in the benefits summary section. Based on the requirements of the organization, admins can additionally customize the benefits summary section and use any limit types from the Health Information Knowledgebase.
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