Coverage & Billing | Individual Management | True Care System Documentation

Screen Overview

New Individual Coverage and Billing tab — New Individual — Coverage & Billing tab.

Coverage & Billing is the second tab in the New Individual workflow. Complete the available payer and billing information as accurately as possible. When required details are unavailable, save the record as a draft and return after verification.

Page Actions

Action	Description	When to Use
Back	Returns to the previous Individual page.	Use when leaving the creation workflow.
Restore Draft	Restores previously saved draft information.	Use when continuing an incomplete record.
Save	Saves current progress without creating the final Individual.	Use when payer or billing information is incomplete.
Create Individual	Creates the Individual after required validation passes.	Use after required information has been reviewed.
Clear this tab	Clears values entered on the Coverage & Billing tab.	Use carefully when restarting this section.
+ Add Secondary	Adds another insurance payer after the Primary Payer.	Use when the Individual has secondary coverage.

Insurance Payers

The Insurance Payers section stores the Individual's Primary Payer and, when applicable, one or more Secondary Payers. Enter information from current payer cards, enrollment records, eligibility responses, or approved payer documentation.

Field	Description	Requirement or Guidance
Payer Name	Name of the insurance payer or managed care organization.	Required for the Primary Payer.
Plan	Specific insurance plan, product, or program associated with the payer.	Enter when shown on the coverage record.
Eligibility	Current coverage status, such as Pending, Active, or another available status.	Update after eligibility verification.
Member / Policy ID	Member, subscriber, recipient, or policy identifier assigned by the payer.	Required when applicable to billing.
Group #	Employer, plan, or payer group number.	Optional unless required by the payer.
Start Date	Date coverage begins.	Use MM/DD/YYYY.
End Date	Date coverage ends, when known.	Leave blank when coverage is ongoing and the payer allows it.
Notes	Additional eligibility, copay, reference number, or payer-specific details.	Do not enter unnecessary sensitive information.

Payer Verification

Do not rely only on an insurance card. Verify current eligibility, coverage dates, member identifiers, payer requirements, and authorization status before billing.

Primary and Secondary Payers

Primary Payer

The Primary Payer is the payer expected to be billed first according to the Individual's current coverage and coordination-of-benefits rules.

Secondary Payer

Use + Add Secondary when another payer may be responsible after the Primary Payer. Secondary coverage should be entered in the correct billing order.

Confirm which payer is primary before submitting claims.
Do not assume Medicaid is always primary.
Review Medicare, commercial insurance, managed care, waiver, and program rules.
Update payer order when coverage changes.
Retain effective dates for historical billing review.

Eligibility Status

Eligibility indicates whether coverage is currently verified or still awaiting review. The available system list may include statuses such as Pending or other Provider-defined values.

Status	Description	Recommended Action
Pending	Eligibility has not yet been fully verified or supporting information is incomplete.	Complete verification before billing.
Active	Coverage has been verified for the applicable service period.	Continue to monitor effective dates and authorization limits.
Inactive / Ended	Coverage is no longer active for new dates of service.	Do not bill dates outside the valid coverage period.

Authorization Summary

The Authorization Summary provides a high-level view of authorized services connected to the Individual. The screenshot indicates that authorization rows may be implemented or populated through the Authorization module.

Column	Description	Use
Service Code	Authorized service identifier.	Matches the approved service.
Description	Service description.	Helps users confirm the correct service.
Approved	Total authorized units or amount.	Used to monitor the approved limit.
Used	Units or amount already consumed.	Supports utilization review.
Start	Authorization effective date.	Defines the first valid service date.
End	Authorization expiration date.	Defines the last valid service date.

Authorization Dependency

Insurance coverage does not replace service authorization. Services must meet both payer eligibility and authorization requirements before billing.

Billing Address

Select Same as primary home address when the Individual's billing address matches the Primary Address entered on the Profile & Contacts tab.

Keep the option selected when both addresses are the same.
Clear the option when claims, statements, or correspondence require another address.
Verify address changes before billing or mailing financial documents.
Do not use an emergency contact address unless it is also the approved billing address.

Guardian / Representative Payee

This section records the person legally or financially responsible for receiving information, assisting with decisions, or managing benefits on behalf of the Individual.

Field	Description	Guidance
Guardian / MPOA Name	Name of the legal guardian or medical power of attorney.	Verify the applicable legal documentation.
Guardian Phone	Primary phone number for the guardian or MPOA.	Keep current for consent and communication needs.
Representative Payee Name	Name of the person or entity managing benefits or payments.	Enter only when formally designated.
Rep Payee Phone	Primary phone number for the representative payee.	Verify before financial communication.

Authority Verification

A contact name alone does not establish legal authority. Confirm guardianship, medical power of attorney, representative payee status, and disclosure permissions using approved documentation and Provider policy.

Validation Checklist

Primary Payer is selected when coverage applies.
Member or Policy ID matches the payer record.
Eligibility status reflects the latest verification.
Coverage Start and End Dates are accurate.
Secondary Payers are entered in the correct billing order.
Authorization requirements are reviewed separately.
Billing Address is correct.
Guardian and Representative Payee authority is verified.
Phone numbers use valid formats.
Notes include only necessary billing or eligibility information.

Best Practices

Verify eligibility before the first service date and before billing.
Recheck eligibility when coverage, payer, or plan information changes.
Use effective dates instead of overwriting historical coverage meaning.
Review coordination of benefits before selecting the Primary Payer.
Confirm Member or Policy IDs directly from approved payer records.
Do not bill services outside coverage or authorization dates.
Document eligibility reference numbers or important payer notes when required.
Keep guardian and representative payee information current.

Security and HIPAA

Coverage & Billing contains protected health information, payer identifiers, financial information, eligibility details, guardian information, and representative payee information.

Access only records required for assigned job duties.
Apply role-based access and the minimum necessary principle.
Do not share insurance cards or payer identifiers through unapproved channels.
Verify identity and authority before discussing coverage or billing with another person.
Do not include unnecessary medical or financial details in Notes.
Record access and changes through Audit Logs where applicable.
Use approved secure methods when sending payer or eligibility information.

Troubleshooting

The payer is not available in the Payer Name list.

Confirm that the payer is configured and Active for the current Provider. Contact an authorized administrator when payer setup is missing.

The Member or Policy ID is rejected.

Verify the identifier format, remove accidental spaces, and compare it with the current payer card or eligibility response.

Eligibility remains Pending.

Complete the required eligibility verification process and update the status after receiving a valid payer response.

Authorization Summary is empty.

Confirm that an authorization has been created and linked to the Individual in the Authorization module. The summary may remain empty until authorization data is available.

The Billing Address is incorrect.

Review the Primary Address on Profile & Contacts. Clear the same-address option when a different billing address is required.

Secondary coverage is missing.

Select + Add Secondary and enter the additional payer in the correct coordination-of-benefits order.

Frequently Asked Questions

Can I create the Individual while eligibility is Pending?

The system may allow the record to be created, but services should not be billed until eligibility and authorization requirements are verified.

Is the Payer Name the same as the Plan?

No. The Payer Name identifies the insurance company or managed care organization. The Plan identifies the specific product, benefit, or program.

Can an Individual have more than one payer?

Yes. Use Primary and Secondary Payer entries according to coordination-of-benefits rules.

Does active insurance mean the service is authorized?

No. Eligibility confirms coverage status. Authorization confirms that a specific service, amount, and date range are approved.

Can payer information be edited later?

Yes. Authorized users may update payer information after locating the Individual through Search Individual. Preserve historical accuracy when coverage changes.

Who should be entered as Representative Payee?

Enter only the person or organization formally designated to manage benefits or payments for the Individual.