Capitation Setup Process

The following steps should be performed to set up Capitation plans within CGM webPRACTICE.

Setup Steps
  1. Set up an Insurance Carrier code - Tables, Insurance Carrier Table, Maintain Insurance Carriers. You must use separate codes for each capitated insurance carrier.

  2. Create a Billing Group for each capitation plan - Tables, Billing Group Table, Maintain Billing Group Codes

  3. Create two Payment Codes (FFS & Cap) - Tables, Payment Code Table, Maintain Payment Codes

  4. Create three Adjustment Codes ( FFS, Cap & Offset) - Tables, Adjustment Code Table, Maintain Adjustment Codes

  5. Create a dummy patient account for each capitation plan. - Patient, Patient Registration. For example, Aetna Capitated. We recommend you use 'Capitated' for the last name and the 'insurance company name' for the first name. You will use this account to post the capitation payment.

  6. Create the Capitation Schedule - Tables, Capitation Schedule Table, Maintain Capitation Schedule. Select either Included or Excluded.

    Included - Indicates Procedure Codes that are included in the Capitation Schedule and will be written off.
    Excluded - Indicates Procedure Codes that are excluded from the Capitation Schedule (Fee-for-Service), and will not be written off.
    We recommend you review the insurance company's Schedule of Benefits to determine which list of codes is smaller - codes to be included or codes to be excluded, and set up the schedule accordingly.

  7. Enter each Procedure Code in the Capitation Schedule - Tables, Capitation Schedule Table, Enter Capitated Procedure Codes
For information about posting capitation payments and the month-end capitation process, see Capitation Functions under the Managed Care menu.