How to add Insurance Details

🌐 Overview

With Helix, you can:

• Add and manage Insurance Companies and TPAs.

• Configure networks, service-type discounts, and global DRG factors.

• Upload or manually enter price lists for each network.

• Set up eligibility and approval requirements for automated insurance workflows.

These settings directly impact insurance claims, pre-approvals, and invoice calculations within the system.

Configuration

🧭 Step 1: Add an Insurance Payer / TPA

Path: Control Panel → Insurance

1. Click ➕ Add (top-right corner).

2. Fill in the following details:

   • 🏢 Branch – Select the branch(es) the insurer applies to.

   • 🏷️ Name – Enter the name of the insurance company or TPA.

   • 📂 Type – Choose Insurance or TPA as appropriate.

   • 💰 Ledger – Link the ledger account (Finance can assist with selection).

   • 🆔 Company Code –

     • For TPAs, use the format TPA…

     • For Insurance companies, use the format INS…

   • ⚙️ Require Eligibility – Toggle ON if pre-authorization is required before billing.

   • 🧾 Require Approval – Toggle ON if claims require approval.

   • Add other details as required (phone, email, address, TRN, etc).

3. Click ✅ Submit.

   • The new payer or TPA will now appear in your Insurance list.

⚙️ Step 2: Configure Networks and Terms

After adding the payer, click Open (from the right-side row menu) to begin configuration.

What are Networks?

In healthcare insurance, a Network refers to the group of hospitals, clinics, doctors, pharmacies, and other healthcare providers that have a contractual agreement with an insurance company or TPA (Third Party Administrator) to provide services to insured patients at predefined rates.

What are DRG Codes?

DRG codes are a way for hospitals and insurance companies to classify types of medical treatments or hospital stays into groups that have similar medical conditions and similar costs.

Each DRG represents a specific category of care — like a type of surgery, treatment, or hospital admission — and has a fixed reimbursement rate agreed upon with insurance companies.

🌐 Networks Setup

• Click the 🌍 Globe icon (top-right corner) to add a network.

• Enter the Network Name and an optional DRG Code (for day-care/surgery).

• You can create multiple networks if the payer manages more than one.

• If all networks share the same DRG factor, you can set it later under Service Type Discounts.

💸 Service Type Discounts

If your insurance agreement defines different discount rates by service type:

• Enter percentage discounts for specific categories such as:

  • 🩺 Consultation

  • 🧪 Clinic

  • 🧫 Investigation

  • ⚕️ Surgery

• Use the provided fields for each service type.

• Click the Save button beside each field to record your entries.

• (Optional) Add a Global DRG Factor here if it applies uniformly to all networks.

📌 Multiple discount fields are available—Helix lets you manage complex payer rules flexibly.

🧾 Policies (KSA Reference)

This section provides a historical view of policies for reference.

Note: This is used mainly for Saudi Arabia-based workflows.

📊 Step 3: Price Lists (Default & Network-Specific)

Each insurance setup includes a Default Price List and additional tabs for every created network.

You can either upload prices in bulk or add them one by one.

🔼 Bulk Upload Method

1. Click Upload Price List (red button).

2. Prepare an Excel file with two columns:

   • Column A: Service Code (index 0)

   • Column B: Price (index 1)

3. Follow these formatting rules:

   • No empty cells — fill blanks with 0.

   • No formulas — values only.

   • Use a dot (.) for decimals (no commas).

   • Codes must match your master service codes.

4. During upload:

   • Choose the Network (or leave blank to upload to Default).

   • Set Code Column = 0, Price Column = 1.

   • (Optional) Turn ON Replace Current Price List to overwrite existing entries.

5. Click Confirm.

   • A green success message will show the total number of uploaded lines.

🧩 Add Price List Manually

1. Click Add Price List (blue button).

2. Choose the Network (or Default).

3. Select a Service from the master list.

4. Enter the Rate for that service.

5. (Optional) Toggle Full Value to prevent additional discounts from being applied.

6. Save the line and repeat for all required services.

   • You can also include Consumables if applicable.

📁 Step 4: Review & Manage Insurance Setup

• You can add, edit, or delete networks and price lists anytime using the row menu (⋮).

• Use Export to Excel or Print PDF options for easy reporting.

• Verify the linked ledger account to ensure proper posting in Finance.

💡 Pro Tips

💎 Use clear and consistent naming for insurers and TPAs (e.g., “INS–AXA” or “TPA–NAS”).
🧾 Always double-check that codes in the uploaded Excel match your master service codes.
📊 Use the Global DRG Factor when the same multiplier applies across all networks—it saves time.
📍 Review discount entries periodically to ensure they align with updated insurance agreements.
🚫 If a service is not priced in the list, it will default to the master cash rate, not the negotiated one.