Insurance Carveouts [Avea Integrations]

When adding insurance to the prospect record in the CRM, you can document behavioral health carveouts for each payor (e.g., primary, secondary, tertiary, etc.). Carveouts allow you to indicate when specific services should bill to the carved-out payer instead of the patient's primary payer and is common for behavioral health-related services. 

For organizations integrated with Avea RCM for billing, these insurance carveouts will be transferred to the insurance section of the prospective patient record in Avea. 

Add Insurance and Carveouts

After you've created the Prospect Record, add the patient's insurance information. You'll need to add the medical payer first and then add a second record for the carveout payer.

1. First, let's add the patient's primary insurance. Click on the Insurance List from the prospect record. 
   
2. Then, click Add Patient Insurance.
3. Select the Insurance Type.
4. Select the Tenant Payor.
5. Enter the Effective Date.
6. Enter the Member ID.
7. Complete the Subscriber Information section (at minimum complete the Subscriber Relationship and Gender fields).
8. Because it is possible to make other fields required under Settings, you may see additional fields marked with asterisks (*). These fields must also be filled out before you continue. 
9. Once all required fields have been completed, click on the Save Changes button to finalize.
10. Next, let's add the insurance carveout for behavioral treatment. Click Add Patient Insurance.
11. Select Carveout for the Insurance Type.
12. Select the Tenant Payor. This is the carveout payor for behavioral health. If you need to add a new payor, please follow this process.
13. Select the insurance that this carveout applies to. This field will only display insurances already added to the prospect record.
    • Note: Avea will only accept one carveout for each insurance position. 
14. Enter the Member ID and set the Effective Date.
15. Complete the Subscriber Information section (at minimum complete the Subscriber Relationship and Gender fields).
16. Once all required fields have been completed, click on the Save Changes button to finalize.
17. The insurance and carveout information is available in Avea under the prospective patient's Insurance tab.
18. To view, click on the Primary insurance link.
19. The behavioral carveout appears in the Behavioral Claim Payer section.

Data Flow and Automatic Updates

While the patient is still a prospect, any changes made in the CRM are received in Avea. However, once the patient is admitted into the EMR, Avea stops receiving information about the patient from the CRM. All info needs to be updated in the EMR/Avea after the patient is admitted/transferred to the EMR. Avea will always be the source of truth for the patient's insurance after admission.

FAQs

How will the Avea know which services to send to the carveout vs. primary? 

During service configuration in Avea (which is the process of setting up all the charges and their related price), you will indicate if the particular code should be billed to the medical (primary) or behavioral (carveout) payor. Then, when the claim is created in Avea, the system will reference the service configuration to determine who to bill for the charge (e.g., Drug screen is sent to medical while IOP is sent to behavioral). Billers can review the claims from the Submit Claim screen to ensure the right services are being billed to the right payor. 

How are carveouts displayed in the Kipu EMR?

Once the treatment opportunity is pushed to the EMR and accepted, you can view the patient's medical insurance on the facesheet. Today, the EMR will not display carveouts. These can be viewed in Avea by clicking the Manage Insurance button.