Insurance Groups and Price Lists
Explains how insurance groups and price lists are configured and how they control insurance-based pricing during billing.
Overview
Insurance price lists are used to determine the pricing applied when an insurance provider is selected during patient billing.
To support multiple pricing models under a single insurance provider, the system introduces Insurance Groups.
Insurance groups allow administrators to categorize pricing structures based on different business scenarios.
Examples include:
- Senior citizen pricing
- Pediatric pricing
- Corporate partnership pricing
- Special discount programs
This structure helps prevent duplication of price lists and simplifies pricing configuration management.
Mapping Rules
The system enforces a strict mapping rule between insurance providers, insurance groups, and price lists.
Each combination of:
Insurance Provider + Insurance Group
can only map to one insurance price list.
However, a single insurance provider may have multiple price lists when mapped with different groups.
Example Scenario
Insurance Provider: ABC Insurance
Groups configured:
Group A – Senior Citizens
Group B – Pediatric
Price Lists:
Default Price List (no group)
Senior Citizen Price List
Pediatric Price List
Resulting mapping:
| Insurance | Group | Price List |
|---|---|---|
| ABC Insurance | None | Default |
| ABC Insurance | Senior | Senior Pricing |
| ABC Insurance | Pediatric | Pediatric Pricing |
This rule ensures that pricing conflicts cannot occur during billing.
Configuration Locations
Insurance Groups
Insurance groups can be managed from:
Finance Module → Insurance Management → Insurance Groups
Administrators can:
- Create insurance groups
- Modify existing groups
- Organize insurance configurations
Insurance Price Lists
Insurance price lists can be configured from:
Lab Admin Module → List and Group Management
From this module administrators can:
- Create new insurance price lists
- Map tests and services with insurance-specific prices
- Associate price lists with insurance providers and insurance groups
Configuration changes in this module directly impact billing and claim calculations.
Overview
This documentation explains the Insurance and Claim Management system implemented in LIMS including insurance configuration, billing workflows, eligibility verification, and claim lifecycle management.
Billing with Insurance
Describes how insurance price lists are applied during patient billing and how multiple insurance providers are handled.