Creating a Coverage Policy for Employer Memberships

Creating a coverage policy for employer memberships allows employers to cover part of the costs for procedures and items. Follow these steps to configure an employer coverage policy in SigmaMD.

Step 1: Navigate to Coverage Policies

• Go to Billing > Memberships > Coverage Policies.
• Click Add Employer Policy.

Step 2: Define the Coverage Policy Rules

• Policy Name: Choose a name for the coverage policy.
• Select Employer: Choose one employer for this policy.
• Membership Plan: Only memberships associated with the selected employer will be displayed. Select one or more plans to include.

Rule Settings

• Category: Apply coverage to a specific category or select "All categories."
• Items: Apply coverage to a specific item or select "All Items."

Price Adjustments

• Discount: Apply a percentage discount to selected items/categories.
• Surcharge: Add a dollar amount to selected items/categories.
• Replace: Replace the dollar amount on selected items/categories.

Employer Expenses Coverage

• Do Not Cover: The employer does not cover any costs for the selected items.
• Cover: The employer covers a defined percentage of the selected items.

Step 3: Saving and Viewing Policy Rules

• Once saved, the rules will appear on the right side of the screen.
• Multiple rules can be created per policy.
• If there are conflicting rules, the rule offering the highest discount to the patient will be applied.

Patient Invoice View

• When an item falls under a coverage policy, hovering over the unit price will display the applied policy values.
• If the employer covers a portion of the cost, the displayed amount reflects the patient’s portion after employer coverage.

• If the patient is linked to an employer membership with coverage, a table will appear below, showing the covered values, which will later be included in the employer’s invoice.

Employer Invoice View

• When an invoice is generated for the employer’s billing cycle, a table below the invoice will display:
  • Memberships charged to the employer.

• Charge items covered by the policy, along with corresponding values.

Creating an employer coverage policy allows seamless cost-sharing between employers and patients. If you need further assistance, contact SigmaMD support.