MADPH: How do I enroll a patient in DPH's System when they have insurance now but they didn't at the time of Admission?

Clinics need a way to enroll patients in DPH retroactively, meaning get them into the DPH system electronically even if they were admitted many years ago. However, to do this means calling back to some of the data from when they were first admitted to treatment, including how they were covered to pay for this treatment.

Remember! Massachusetts DPH requires that the patient be declared uninsured (“Pays Own Treatment”) or has a valid coverage record for the date of admission to successfully pass an A01 Admission message.

So when you have a situation where a patient was uninsured when they were admitted for treatment and then receives insurance coverage some time after, there are two ways of making sure you can get a successful A01 from the state of Massachusetts.

Option 1: Mark the Patient TEMPORARILY as Self-Pay

The first way is to temporarily mark the patient as paying for their own treatment. We must emphasize the word temporary and caution anyone that chooses this method that:

1. It must be done outside of any expected billing that will be run

2. Users must take care to remove the self-pay designation as soon as the A01 is successful

To leverage this method, simply leave the current coverage record in tact, but then go into the patient’s profile and click on the Billing tab (see below). Mark the patient as ‘pays own treatment’ (you’ll need to enter the fees, bill cycle, etc.) – be sure to enter an extended bill cycle (monthly or yearly, perhaps).

The SMART validation will pick this up in the following day’s validation check as a “uninsured” for the A01 (Admission) date.

As soon as the A01 is in pending, remove the ‘pays own treatment’ check box so that it will go back to defaulting to their insurance and there’s no threat that the patient gets billed or the clinic generates invalid revenue. 

Option 2: Setup a Coverage Record Mapped to “Uninsured” and Make the From and Through Date their Admission Date

You may already have a way of tracking that a patient was uninsured by using a Self-Pay carrier. If you do not, one will need to be set up. It’s very important to note that this method can and will impact some of what you see on reports in SMART as there are many that show all carrier types. Careful consideration should be given if this is not already a method you use in SMART. Consult your Partner Success Manager if you have questions.

If you do choose this method, then there are a few things you must do to properly set up the carrier as an uninsured carrier.

• The DPH Export Value should be set to “Other”

• The Carrier Type should be set to Uninsured

• The CarrierTypes lookup table must have the Uninsured value linked to an Export Value of UI

For more information on the proper settings, see the following article for help as this is just like how you would set up a carrier type of DPH: MADPH: How Should I Setup Patients Insurance When They Are on DPH for Coverage?

Once the Carrier is properly setup, you will want to create a coverage record for the patient that covers only the date range of the Admission timeframe. This is important so that it does not overlap with insurance coverage records. Having a self-pay or uninsured carrier coverage record for the admission date in SMART will allow the A01 to successfully pass to the state indicating that the patient was uninsured at Admission.