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