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 + Policy and select the Employer option.

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

  • Charge Item or Shipping
    • Charge item:
      • Category: Apply coverage to a specific category or select "All categories."
      • Items: Apply coverage to a specific item or select "All Items."
    • Shipping: Apply coverage to shipping labels.

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.
  • Employer covers up to: The employer will cover costs up to the defined percentage or dollar amount of the selected items.

Employee pays up to: The employee will pay costs up to the defined dollar amount 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.

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.

unnamed (75).png

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