Billing Rates Vary by Network

The following table provides at a glance the rate template for Billing Rates Vary by Network.

Billing Rates Composite Rates

Group Benefit Plan Setup

Rate Template (header) file & Import Fields

A benefit plan setup as follows:

Insurance Class = Medical, Dental or Vision

Family Rated Premium = No

Termination Date = [blank] OR Date > current date

Tobacco Banded Rates = No

Gender Banded Rates = No

Spouse Gender Banded = No

Wellness Banded Rates = No

Age Banded Medical Rates = Yes or No

Billing Rates Vary By Network = Yes

Benefit Plan ID

Network ID

Plan Type

Effective Date

From Age

To Age

Total Bill Amount

Employee Bill Amount

Dependents Bill Amount

Note: You must have access to the Billing Rates Groups to perform this action.

Please make a note of the following errors to avoid while preparing your import file using this template:

For Plan ID

You can only select an active plan for the import. If you select a plan that is terminated you will get an error message stating Plan ID is Terminated. Not valid for Import.

If the Family Rate Premium field under the Other Processing Parameters section on the Group Benefit Plans form is checked, then exclude family rated plans from the import. If not you will get an error message stating Plan ID has Family Rated Premium. Not supported for Import.

Medical, Dental and Vision plans are currently supported. If you select any other insurance class plans, you will get an error message stating Plan ID is [NAME] Insurance Class. Not supported for Import.

Plans where the Manual Calculation field is set to Coverage & Premium Entered Manually in the Group Benefits Plan form are excluded.

The following are required values on the import. [Benefit Plan ID, Network ID, Plan Type, Effective Date, Total Bill Amount and Employee Bill Amount]. If the import file is missing any required values, you will see an error message stating {Import Field Name} is required.

If the benefit Plan ID on the import file;

does not exist in PrismHR, then you will receive an error message stating Plan ID <Plan ID> does not exist.

is more than 25 characters, you receive an error message stating Benefit Plan ID must be 25 characters or less.

is NOT in the list of Benefit Plan IDs in the Template Builder you will receive an error message stating Plan ID <Plan ID> is not in the Template Builder and cannot be included in this Rate Template.

Age Banded Medical Rates

If Age Banded Medical Rates = No, then only one line of rate is allowed.

If the import file has more than one rate for the same Effective Date then you will receive an error message stating Plan ID <Plan ID> is not setup as age banded. Therefore, only one age band is allowed (0 to 99).

ii.

If the From Age and To Age fields are on the import file, then the From Age must be 0 and To Age must be 99. If any other value is entered, you will receive an error message stating From Age must be 0. To Age must be 99.

iii.

If the From Age and To Age fields are blank on the import file, then PrismHR will import the values of 0 for the From Age field and 99 for the To Age field.

If Age Banded Medical Rates = Yes, then multiple lines of age rates are allowed (For example: age 0 - 19, 20-39, 40-59, 60-99). However:

If import file is set up with overlapping From Age and To Age for same Effective Date combination, you will receive an error message stating Age Bands cannot overlap.

ii.

Import file should not have gaps between age bands. For example you cannot have age bands like 0-19, 20-29, 31-39 since the To Age of 29 and From Age of 31 have a gap. If there are gaps, you will receive an error message stating Age gaps are not permitted in Age Banded Rates.

iii.

The From Age and To Age fields must be a whole number >=0, otherwise you will receive an error message stating [From Age/To Age] must be a whole number >=0 From Age or To Age = whichever is applicable to error.

iv.

Initial From Age must be 0, otherwise the import will fail with an error message stating Initial From Age must be 0.

If employee Plan Type on the import file does not exist under the section Plan Types on the Group Benefit Plan form, you will receive an error stating Plan Type <Plan Type> does not exist on the Plan ID <Plan ID>.

Network ID on the import must exist under the section Plan Networks on the Group Benefit Plan form. If not import line fails with error message stating Network ID <Network ID> does not exist on Plan ID <Plan ID>.

If the Effective Date on the import file is not in a valid US date format, you will receive and error message stating Effective Date must be in a valid date format.

If your import file has records which already exist in PrismHR having the same Benefit Plan ID, Network ID, Plan Type and Effective Date, then you will receive an error message stating Effective Date <EFFECTIVE DATE.> already exists for this record. Updates cannot be imported. If a duplicate key exists on the import file, this validation will also present a line error for the second record and any subsequent duplicate records attempted to be imported.

The rate on the import file has to be a positive number with a maximum of 2 decimals. If the rate on the import file;

has more than 2 decimals, then you will receive an error message stating Only 2 decimal places are allowed for Rates.

is negative, you will receive an error message stating Negative amounts are not allowed.

10.

Total Bill Amount must equal Employee Bill Amount PLUS Dependent Bill Amount. If Employee Bill Amount is on the import file and Plan Type has Coverage Class selected as Single (employee) coverage on the Group Benefit Plan Types form, then Employee Bill Amount must equal Total Bill Amount, otherwise the import will fail with the following error message:

Plan Type Coverage Class can be found in Group Benefit Plan Types in the Coverage Class field.

Plan Type <Plan Type> has Coverage Class Single. Employee Bill Amount must equal Total Bill Amount.

11.

If Dependent Bill Amount > 0 is on the import file and Plan Type has Coverage Class selected as Single (employee) coverage on the Group Benefit Plan Types form, the import will fail with an the error message stating Dependent Bill Amount > 0 is not allowed for Plan Type <Plan Type>.

12.

Dependent Bill Amount is a calculated amount based on Total Bill Amount minus Employee Bill Amount.

If Dependent Bill Amount is on the import file and Plan Type has Coverage Class NOT selected as Single (employee) coverage on the Group Benefit Plan Types form, the Employee Bill Amount PLUS the Dependent Bill Amount must equal the Total Bill Amount. Otherwise, the import will fail with an error message stating Employee Bill Amount PLUS Dependent Bill Amount must equal the Total Bill Amount.

If Dependent Bill Amount is blank on the import file, then Dependent Bill Amount will be imported as a calculated amount. (Total Bill Amount minus Employee Bill Amount)