The Payment Entry Approved Amount is the amount the insurance carrier will pay regardless of what was charged for the procedure. The Approved Amount may or may not be the same amount as the procedure's Allowed Amount.
The Approved Amount is determined by the following steps:
If you maintained an Alternate Fee for the procedure, INSight will look for the Alternate Fee table for the insurance and procedure which is keyed by "Ins + Proc". If this table exists, it has up to ten "date ranges" that can be checked to see if the charge Service Date falls within one of the ranges. If the Service Date does fall within one of the ranges INSight uses the Allowed Amount on the table for that range. Regardless of whether INSight finds an allowed amount from this table it checks an even more specific Alternate Procedure table which is keyed by "Ins + Proc + Prov" with the same date ranges. The values on this specific table will override the previous value if it exists.
If INSight does not find values in the Alternate Procedure tables then INSight checks the Alternate Provider tables which are keyed by "Proc + Provider". If the appropriate table is found, the Allowed Amount is taken from there.
However, if no values were found in any tables then INSight uses the Procedure's Form Type Allowed Amount. If this is also zero then the Allowed Amount defaults to the fee (procedure's Standard Fee or Alternate Fee for the Form Type if maintained) maintained on the ticket.
The value determined by the steps above is multiplied by the charge number of units maintained on the ticket to arrive at the Payment Entry Approved Amount and the Total Allowed amount.
The Total Allowed field is maintained on the payment detail transaction line when using the By Ticket Cash Application Method (payment method 3). This is a separate field from the Allowed Amount field displayed next to the Total Allowed. The Allowed Amount is the Total Allowed amount, or if Total Allowed is greater than the actual ticket balance then the Allowed Amount is set to the balance on the ticket to prevent you from getting paid more than you charged. The Total Allowed amount is also maintained as the Approved Amount located above and to the right of the Payment Entry OK button. The Approved Amount can not be edited and always remains the same even if you edit the Allowed Amount. This way you always have a reference of what the real Approved Amount is.
Tip: If you are using the By Detail Cash Application Method (payment method 1), the Approved Amount displays (using the above calculations) as a reference to indicate how much you should be getting paid.
See also: Allowed Amount, Alternate Fee, Standard Fee
Where-Maintained: Payment Entry - Transaction Detail Entry By Detail, Payment Entry - Transaction Detail Entry By Ticket
Format: 7.2 numeric