Intellect™
APPROVED AMOUNTS
During the process of posting charges, Intellect utilizes an order of selection to determine the approved amount for each procedure. Since the Approved Amount is calculated at the time the charge is posted, it is important that Regular --► Patient Insurance --► Add Insurance <Pay Plan> is completed at the time of registration and the system set up is correct before charge posting begins.
Fee Schedule Hierarchy Summary
1st: Intellect checks for an exact match of the patient’s Primary Insurance screen <Insurance Company Name> and the Charges --►Charge <Provider> field.
2nd: If the above is not found, Intellect checks the <Insurance> and <Provider> fields for the <Pay Plan> indicated on the patient’s Primary Insurance screen.
3rd: If the above is not found, Intellect checks the <Insurance> and <Provider> fields for the <Pay Plan> indicated on the patient’s Primary Insurance screen, and also checks the patient’s Primary Insurance <Insurance Company Name>.
4th: If the above is not found, Intellect checks the <Insurance> field for the <Pay Plan> indicated on the patient’s Primary Insurance screen, and also checks the Charges --►Charge <Provider> field.
The remainder of this document covers the
• Conditions that Affect Results
• Menu Paths, Screens, and Field Names
Update 9.10.21: Identifying the Pay Plan
Based on the system set up when charges are posted, Intellect records many pieces of information regarding the patient, insurance, and charge as it was at the time of posting. Some examples are the patient’s category code, primary insurance, approved amount, the percentage of the approved amount the primary insurance is expected to pay, and, if the patient has a capitated plan, is the charge a ‘carve out’ procedure*, etc. Much of this is calculated using information set up in a Pay Plan table. The program uses a defined hierarchy to determine which Fee Schedule and/or Pay Plan to use. Another level has been added to the hierarchy to determine which, if any, Pay Plan code to apply. For example, compare the versions below on Calculating the Approved:
Prior to update 9.10.21:
To match the services posted with a Pay Plan and Fee Schedule, Intellect would look first to find a match in the Utility --►Procedure --►Fee Schedule table with the Provider/Dr (not the Billing Provider), Patient Primary Insurance, and posted Procedure code (not the Panel Code). If a match was not found, the program would retrieve the Patient Insurance screen <Pay Plan> code.
Effective update 9.10.21:
If a match is not found in the Utility --►Procedure --►Fee Schedule table, and the Patient Insurance screen <Pay Plan> field is blank, or the code entered is invalid, Intellect uses the Provider code entered during charge posting to match to the Utility --►Insurance --►Pay Plan --►Pay Plan <Provider Code> field. If the <Provider> code on the Charges --►Charge screen matches the <Provider Code> on Utility --►Insurance --►Pay Plan --►Pay Plan, Intellect uses that Pay Plan record.
From this point forward, Intellect works as it previously has.
* Identifying Carve Out services:
Prior to update 9.10.21: To determine whether or not a procedure should be carved out when the patient’s Category <Type> is P or Q, Intellect retrieves the Patient Insurance screen <Pay Plan> code.
1. Intellect looks for a Utility --►Procedure --►Fee Schedule for the posted Provider, Insurance, and Panel Code:
1.1 If a match is found, the Approved equals the Fee Schedule <Approved>.
1.2 If a match is not found, Intellect goes to item 2.
2. Intellect looks at the Registration --► Regular --► Patient Insurance <Pay Plan> and, if completed, the system reads the Pay Plan <Insurance Code> and <Provider Code> fields.
2.1 If completed, the system reads the Utility --►Insurance --►Pay Plan <Insurance Code> and <Provider Code> fields.
2.1.1 Intellect looks for a Fee Schedule for the Utility --►Insurance --►Pay Plan <Insurance Code> and <Provider Code> and Panel Code posted.
2.1.2 If a match is found, the Approved equals the Utility --►Procedure --►Fee Schedule <Approved>.
2.1.3 If a match is not found, the Approved equals the Utility --►Procedure --►Procedure <Charge Global>.
2.2 If the Patient Insurance <Pay Plan> is not completed, the Approved equals the Utility --► Procedure --► Procedure <Charge Global>.
2.3 If the Utility --►Insurance --► Pay Plan --►Pay Plan <Insurance Code> and <Provider Code> fields are not completed, Intellect goes to item 3.
3. Intellect looks at the Utility --►Insurance --► Pay Plan --► Pay Plan <Allowable R/F/N>:
3.1 If the Pay Plan <Allowable R/F/N> = 'F,' the Approved equals the Utility --► Procedure <Charge Global>.
3.1.1 If the Pay Plan <Multiplier> = 0 or is blank, the Approved equals the Utility --►Procedure <Charge Global>.
3.2 If the Pay Plan <Allowable R/F/N> = 'R,' Intellect looks at the Utility --► Insurance --► Pay Plan <Scale Code> and <Unit Value Pointer>. The system calculates the Approved from the Utility --► Procedure --► Unit Value <Global 1>, 2 or 3 (dependent on <Unit Value Pointer>) multiplied by the Utility --► Insurance --► Pay Plan <Conversion> (dependent on Procedure <Conversion>).
3.2.1 If the Pay Plan <Scale Code> has a value but the <Unit Value Pointer> = 0 or is blank, Intellect assumes a pointer value of '1.' The system calculates the Approved from the Utility --► Procedure --► Unit Value <Global 1> multiplied by the Utility --►Insurance --►Pay Plan <Conversion> (dependent on Utility --►Procedure <Conversion>).
3.2.2 If the Pay Plan <Scale Code> is blank, the system calculates the Approved from the Utility --► Procedure <Unit Value> multiplied by the Utility --►Insurance --►Pay Plan <Conversion> (dependent on Procedure <Conversion>).
3.2.3 If the Pay Plan <Scale Code> and <Unit Value Pointer> are completed but the Procedure is not entered in the Utility --►Procedure --► Unit Value <Panel>, the system calculates the Approved from the Utility --►Procedure <Unit Value> multiplied by the Utility --►Insurance --► Pay Plan --►Pay Plan <Conversion> (dependent on Procedure <Conversion>).
3.2.4 If the Utility --►Insurance --► Pay Plan --►Pay Plan <Scale Code> and <Unit Value Pointer> are completed and the Procedure is entered in the Utility --►Procedure --► Unit Value <Panel> but no value is entered in Unit Value <Global 1>, 2 or 3 (dependent on Utility --►Insurance --►Pay Plan <Unit Value Pointer>, the Approved equals the Utility --►Procedure <Charge Global>.
Conditions that Affect Results:
1. Utility --►Procedure --►Procedure <Conversion> 
This field is used to determine which field in the Utility --►Insurance --► Pay Plan --►Pay Plan <Conversion 0 (or 1, 2, 3, 4)> field entry to use for this procedure.
Intellect then multiplies the conversion factor by the number in the appropriate Utility --►Procedure --► Unit Value selection for this procedure to calculate the approved amount.
2. Utility --►Procedure --►Modifier
A modifier may be attached to the procedure or added or changed at the time of posting.
Depending on the Modifiers' configuration, two key factors could influence the value of the approved associated with the posted procedure Modifier <INC/DEC (I/D/N)>:
2.1 If the Modifier <Multiplier> is completed:
2.1.1 And Modifier <INC/DEC (IDN)> is set to 'I' (Increase), Intellect multiplies the Approved amount by the Modifier <Multiplier> and increases the Approved amount.
2.1.2 And Modifier <INC/DEC (IDN)> is set to 'D' (Decrease), Intellect multiplies the Approved amount by the Modifier <Multiplier> and decreases the Approved amount.
2.1.3 And Modifier <INC/DEC (IDN)> is set to 'N', there is no affect on the Approved amount. The Approved amount equals the Utility --►Procedure --►Fee Schedule <Approved>.
2.2.1 If set to 'G' (Global Charge), there is no affect on the Approved amount. The Approved amount equals the Utility --►Procedure --►Fee Schedule <Approved>.
2.2.2 If set to 'T' (Technical), Intellect calculates the Technical Approved amount by:
2.2.2.1 Subtracting the Utility --►Procedure --►Fee Schedule <Professional Approved> from the Utility --►Procedure --►Fee Schedule <Approved>.
2.2.2.2 OR Intellect multiplies the Utility --►Procedure --►Unit Value <Prof 1>, 2 or 3 (dependent on Pay Plan <Unit Value Pointer>) times the Utility --►Insurance --► Pay Plan --► Pay Plan <Conversion> (dependent on Procedure <Conversion> and subtracting that from the Unit Value <Global 1>, 2 or 3 (dependent on Pay Plan <Unit Value Pointer>) times the Pay Plan <Conversion> (dependent on Utility --►Procedure --►Procedure <Conversion>).
2.2.2.3 OR Intellect multiplies the Utility --►Procedure --►Procedure <Prof Unit Value> times the Utility --►Insurance --► Pay Plan --► Pay Plan <Conversion> (dependent on Procedure <Conversion>) and subtracting that from the Utility --►Procedure --► Unit Value <Global 1>, 2 or 3 (dependent on Pay Plan <Unit Value Pointer>) times the Pay Plan <Conversion> (dependent on Utility --►Procedure --►Procedure <Conversion>).
2.2.3 If set to 'P' (Professional):
2.2.3.1 The Approved equals the Utility --►Procedure --►Fee Schedule <Professional Approved>.
2.2.3.2 OR Intellect multiplies the Utility --►Procedure --► Unit Value <Prof 1>, 2 or 3 (dependent on Utility --►Insurance --► Pay Plan --►Pay Plan <Unit Value Pointer> times the Pay Plan <Conversion> (dependent on Utility --►Procedure --►Procedure <Conversion>).
2.2.3.3 OR Intellect multiplies the Utility --►Procedure --►Procedure <Prof Unit Value> times the Utility --►Insurance --► Pay Plan --►Pay Plan <Conversion> (dependent on Utility --►Procedure --►Procedure <Conversion>).
NOTE: If Utility --►Procedure --►Modifier <Multiplier>, <INCD/DEC (IDN)> are completed and <Charge G/T/PR> is not 'G,' Intellect calculates the Approved amount using <Charge G/T/P/R>.
Menu Paths, Screens, and Field Names:
The paths, screens, and field names used in the Approved calculation portion of the document are listed below. Please note:
• The path and table name are defined on the first line. The last item in the string is the screen name. For example: Utility --►Procedure --►Procedure, or Utility --►Procedure --►Fee Schedule.
• The screen and field name are listed below the path and screen. The field name is within the < > brackets. For example: Procedure <Charge Global>, or Fee Schedule <Provider Code>.
• Within the document, the screen and field names are italicized. For example: Patient Insurance <Pay Plan>.
• Only the screen and field names are in the calculation document, not the menu path. Refer to the list below to find the entire path.
Registration --► Regular --► Patient or Registration --► Worker
Patient Insurance <Pay Plan>
Utility --►Insurance --►Pay Plan --►Pay Plan
Pay Plan <Insurance Code>
Pay Plan <Provider Code>
Pay Plan <Scale Code>
Pay Plan <Unit Value Pointer>
Pay Plan <Allowable>
Pay Plan <Multiplier>
Pay Plan <Conversion 0>, 1, 2, 3 or 4 (as defined by Procedure <Conversion>)
Utility --►Procedure --►Fee Schedule
Fee Schedule <Provider Code>
Fee Schedule <Insurance Code>
Fee Schedule <Panel Code>
Fee Schedule <Approved>
Fee Schedule <Professional Approved>
Utility --►Procedure --►Unit Value
Unit Value <Scale>
Unit Value <Panel>
Unit Value <Global 1>, 2 or 3 (as defined by Pay Plan <Unit Value Pointer>)
Unit Value <Prof. 1>, 2 or 3 (as defined by Pay Plan <Unit Value Pointer>)
Utility --►Procedure --►Modifier
Modifier <Multiplier>
Modifier <INC/DEC (IDN)>
Modifier <Charge G/T/P/R>
Utility --►Procedure
Procedure <Charge Global>
Procedure <Unit Value>
Procedure <Professional>
Procedure <Unit Value> (Prof)
Procedure <Conversion>