Insurance Eligibility

Item Eligibility

Item Insurance Eligibility defines which healthcare services and items are covered under specific insurance plans.

Field	Description
Item	The healthcare service or product
Insurance Payor	Which payor covers this item
Coverage Percentage	What percentage the insurance covers (e.g., 80%)
Maximum Amount	Cap on the coverage amount
Pre-authorization Required	Whether prior approval is needed

Coverage Plans (Eligibility Plans)

Insurance Payor Eligibility Plans group eligibility rules into named plans:

Field	Description
Plan Name	e.g., "Gold Plan", "Silver Plan", "Basic Coverage"
Insurance Payor	The insurance company offering this plan
Covered Items	List of items/services covered under this plan
Coverage Details	Percentage, limits, and conditions for each item

Example: Gold Plan Coverage

Service	Coverage %	Max Amount	Pre-auth
OPD Consultation	100%	Rs. 1,000	No
Lab Tests	100%	Rs. 10,000	No
Minor Procedures	80%	Rs. 25,000	No
Major Surgery	80%	Rs. 5,00,000	Yes
Room Charges	100%	Rs. 5,000/day	No