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Configuring the PRO Urgent Care benefit

Suggest edit Updated on September 10, 2021

The PRO Urgent Care benefit covers services that are related to a visit to a stand-alone urgent care clinic. For example if you fell off a ladder and you went to a stand-alone urgent care clinic, you use this benefit to cover the office visit, labs, and x-rays.

Before you begin

Before you configure this benefit, read the description and perform the required tasks that are listed in Benefits.

Procedure

  1. In the header of Dev Studio, click Launch web interface > Product Development.
  2. In the left navigation panel of your work space, click New > Benefit.
  3. Click New.
  4. In the Name field, enter PRO Urgent Care.
  5. In the Effective date field, enter 1/1/2019, and in the End date field, enter 12/31/9999.
    This end date means that the benefit might be in use indefinitely. By entering 9999 for the year in the end date, you do not have to continually update the end date.
  6. In the Insurance line list, select Medical.
  7. In the Benefit category list, select Urgent-Services.
  8. Click Add Purpose and Alias names. In the Purpose field, click Sales and in the Name field, enter a meaningful name for the benefit that individuals in the business area understand, for example, Urgent Care.
    These fields are optional.
  9. For this tutorial, ignore the optional Client benefit id and Description fields.
  10. Ensure that the Is wellness benefit check box is not selected because this benefit is not a wellness benefit.
    PRO Urgent Care benefit
  11. Click Continue.
  12. In the Define Mapping step of the wizard, define the conditions (codes) to describe the benefit which then is understood by a claims adjudication system.
    1. In the Definition list, select Service group and click Add definition.
    2. Click Add Service Group.
    3. In the Code group field, enter C1010 and select it from the list.
      The Description field displays Therapy occupational.
    4. Click Add Service Group.
    5. In the Code group field, enter H2190 and select it from the list.
      The Description field displays Urgent care.
    6. In the Definition list, select Place of service codesand click Add definition.
    7. Click Add Place of Service Codes.
    8. In the Code group field, enter 20 and select it from the list.
      The Description field displays: Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
  13. For this tutorial, ignore the optional Override section because it does not apply.
    If you are integrated with a downstream processing claim system that requires an indicator to advise when one benefit precedes or overrides another, you select this check box.The systems use this benefit on all claim lines so that the member pays only for the cost shares associated with this benefit.
  14. Click Generate Description to list the benefit description based on the codes that you select.
    Service groups for the PRO Urgent Care benefit

    You can click the Show Detail icon next to the Description field to view the details of the code group.

  15. In the Enter notes step of the wizard, click the SBC Benefits Description tab, and enter PRO Urgent Care benefit is required. Then click Continue.
  16. In the Review benefit step, review the benefit and then click Finish.
  17. Because you have manager credentials, approve the benefit entity by following these steps:
    1. Click Actions > Approve and hold at the top right.
      By selecting Approve and hold instead of Approve, the entity remains in the current stage, but is available for use in other tasks. To advance the entity to the next stage, click Approve.
    2. In the Approve section, click Submit.

What to do next

Configure a facility urgent care benefit. See Configuring the FAC-Urgent Care benefit.

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