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Insurance Price Lists

Create service-specific price lists per insurer with copay and coverage rules

3 min read

Overview

Insurance price lists allow you to define exactly how much each service costs when billed to a specific insurance company, what the patient copay is, and what percentage the insurer covers. This prevents manual calculation errors and ensures consistent billing across all staff members. Each insurer can have multiple price lists (e.g., Gold tier, Silver tier).

Creating a Price List

  1. Navigate to Settings > Insurance > Price Lists — Select an insurance company first, then click the Price Lists sub-tab.
  2. Click "New Price List" — Give the list a name (e.g., "Gold Network 2026") and set an effective date range.
  3. Add service entries — For each service, configure:
    • Service code — The code for this service (e.g., "CONS-GP" for general consultation, "LAB-CBC" for complete blood count)
    • Service name — Descriptive name in Arabic and English
    • Max price (EGP) — Maximum amount the insurer will pay for this service
    • Copay percentage — The percentage the patient pays out of pocket (e.g., 20%)
    • Copay fixed (EGP) — Alternatively, a fixed copay amount (e.g., 50 EGP). If both are set, the system uses whichever results in a higher patient payment.
    • Coverage percentage — The percentage covered by insurance (e.g., 80%)
  4. Save the price list — Click Save. The price list is now active for the specified date range.
Tip: You can duplicate an existing price list and modify it when renewing contracts. Click the "Duplicate" icon on any price list to create a copy with a new date range.
Warning: If a service is not listed in the price list, the system will default to the clinic's standard fee schedule. Ensure all commonly billed services are included to avoid patient disputes.

Price list editor showing service entries with codes, max prices, and copay configurations

How Billing Uses Price Lists

When creating an invoice for an insured patient, the system automatically looks up the patient's insurance company, finds the active price list, and calculates: (1) total service cost from max_price, (2) patient copay from copay_percentage or copay_fixed, and (3) insurance claim amount from coverage_percentage. This auto-fills the invoice breakdown.

Frequently Asked Questions

What if a service has both copay_percentage and copay_fixed?

The system uses the higher amount. For example, if max_price is 500 EGP, copay_percentage is 20% (=100 EGP), and copay_fixed is 50 EGP, the patient pays 100 EGP (the higher of the two).

Can I have overlapping date ranges for price lists?

No. Each insurance company can have only one active price list at a time. If you create a new list with overlapping dates, you will be prompted to adjust the existing list's end date.

How do I handle price increases mid-contract?

End the current price list on the effective date of the increase, then create a new price list starting the next day with updated amounts.

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