Entry of Insurance Relationships 

Use

When transferring PPA data and PPA billing using the AMASYS outpatient billing system, you can enter insurance relationships, such as supplementary insurance, from the existing insurance provider master for a case in SAP Patient Management in addition to the PPA insurance provider.

The system runs checks to determine whether the selected insurance provider matches the visit type and PPA-Relevant indicator in the case data, and displays a message if applicable.

Activities

Make sure the PPA Lock indicator in Customizing is only selected for the visit types you do not want to use for PPA cases.

You can specify a visit type in the preassignments for use when accessing the Clinical Process Builder from other transactions to determine which insurance provider master is to be selected. The system then transfers insurance providers for case categories with a PPA Lock indicator from the existing insurance provider master in SAP Patient Management. Insurance providers for case categories without a PPA Lock indicator are transferred from the PPA insurance provider master.

In the Business Add-In (BAdI) Clinical Process Builder – Preset All Subscreens, you can use field no_kv in structure RNBADI_NCIR when reading the healthcare smart card to control whether or not the system searches for the insurance provider in the AMASYS outpatient billing system. For example, this is useful for organizational units that primarily create Workers' Compensation Association cases rather than PPA cases, since the system always at first assumes that an outpatient case is a PPA case when reading the PPA card if the movement type and PPA-Relevant indicator do not have a default setting that indicates the contrary.

In addition to the existing fields, such as Health Insurer Number and Subgroup, the system now stores the start date of the quarter in which this data is valid in the insurance relationship for PPA cases whose insurance provider is queried using the outpatient billing system. The system enters values in the Ins. From and Ins. To fields in accordance with the validity period in the insurance relationship.

Since this means the insurance relationship can only be used for a quarter, you must perform case accrual at the end of the quarter for the PPA cases. This quarter-dependency means that the insurance relationship cannot be used again from the proposal list of insurance relationships for the patient. The insurance relationship always has to be read again from the PPA card or copied from the PPA insurance provider master in the outpatient billing system using the input help for the Insurance Provider field when a new insurance relationship is created.

The input help has also been connected to the PPA insurance provider master in the outpatient billing system for this purpose, by means of a Web service, so that the relevant search criteria are available as input fields for PPA cases. When a search is successful, the system displays a results list of all the health insurers found in the external PPA insurance provider master for all the insurance provider subgroups. This means a health insurer can appear up to ten times in the list. The number of entries in the list is restricted to the number of lines you specify for list output in Customizing.

Please note that the search takes account of the criteria for the AMASYS outpatient billing system, which means it is not the same as the insurance provider search function in SAP Patient Management. Notably, it is not possible to search for health insurer head offices by their branches. This means, for example, that you cannot search for the Heidelberg branch of AOK Rhine-Neckar by specifying the insurer name 'AOK' and the city 'Heidelberg', but only by searching for the head office in Mannheim by entering the city 'Mannheim' as the search criterion.

 

Case Accrual for Changes to Insurance Data

If you read the healthcare smart card when creating a visit for an existing outpatient PPA case, the system checks the new smart card data against the existing insurance relationship. If the data has changed, you must accrue the case and create a new case.

The system displays a dialog box for this purpose, where you can enter the case accrual date. The system saves the case end date and cancels visit creation.

If you do not want to specify the case end date, the system displays a message (NB 092). You can specify the message type in Customizing for SAP Patient Management.

Warning Message During Manual Entry of an Insurance Relationship

If you create a new insurance relationship for an existing outpatient PPA case, the system displays a message (NB 092). You can specify the message type in Customizing for SAP Patient Management.

 

Input Check when Entering PPA Data

The system transfers the PPA data you enter in SAP Patient Management to AMASYS, where it is checked. AMASYS returns the check results as messages.

During this process, AMASYS checks PPA data from the following transactions in SAP Patient Management:

●      Diagnosis Entry

●      Service Entry

●      Treatment Certificates

The system converts the corresponding data from these transactions to KVDT format and transfers it to the AMASYS outpatient billing system. AMASYS checks the data and returns the check results to SAP Patient Management as messages. The system displays the messages on the treatment certificate overview or detail screen.

For information about the checks in the AMASYS outpatient billing system, see the AMASYS documentation.