Insurance & Panel Management

Administration

Insurance & Panel Management

This page records insurance companies or other payment panels, links patients to a panel, and tracks claims and payments.

Insurance & Panel Management illustration

How to find this page

  1. 1

    Sign in to EliteHMS

  2. 2

    Select the correct location from the top bar

  3. 3

    Choose Insurance from the left menu

Insurance option in the left menu
Insurance in the left menu

Tip:If there are no panels or claims yet, the summary cards show zero values. Start with Add Panel.

What the summary cards show

  • Active Panels: Panels available for use.
  • Insured Patients: Patients linked to an insurance panel.
  • Pending Claims: Claims in Submitted or Under Review status.
  • Outstanding: The unpaid balance on approved or partially approved claims.
  • Paid This Month: Insurance payments marked as paid during the current month.
  • Total Claims: All recorded claims.
Insurance summary cards
Summary cards at the top of the page

Add a panel

  1. 1

    Select Add Panel

  2. 2

    Enter the panel’s details

    Panel / Company Name and Type are required.

  3. 3

    Save the panel

The form also lets you record:

  • Category, such as Health Insurance, EOBI, PESSI, or Corporate HR.
  • Coverage type, percentage paid by insurance, and the patient’s co-pay percentage.
  • Maximum claim per bill and annual limit per patient.
  • Covered services, such as medicines, consultations, lab tests, radiology, IPD, OPD, surgery, or emergency care.
  • Contact person, phone, email, city, agreement or policy number, agreement date, and expiry date.
  • Payment terms and how claims are submitted: online portal, email, physical, WhatsApp, or another method.
  • Portal address, NTN, and notes where relevant.
Add Panel form with coverage, limits, and covered services
The Add Panel form

Warning:Use the actual agreement terms when entering coverage and limits.

The panel card can show expiry reminders, coverage, permitted services, claims, amounts claimed and paid, and payment/submission terms. You can edit a panel later.

Note:A panel cannot be deleted while it has claims recorded against it.

Link a patient to a panel

  1. 1

    Select Link Patient

  2. 2

    Search for the patient

  3. 3

    Choose the panel

  4. 4

    Enter the policy/member number and coverage expiry date

Link Patient form with patient, panel, and policy number
The Link Patient form

Tip:Confirm the patient’s identity and policy details before linking.

Warning:A patient record stores one linked panel at a time. Linking a different panel updates the patient’s current insurance details, so check the existing panel before changing it.

Create a claim

  1. 1

    Select New Claim

    Choose the patient, panel, and total bill amount. The patient should already have the relevant insurance information recorded.

  2. 2

    Review the calculation

    The page calculates an estimated insurance portion and patient portion using the panel’s coverage percentage and maximum claim per bill.

  3. 3

    Indicate whether pre-authorization is required

    If it is, enter its reference number.

  4. 4

    Add submission notes

  5. 5

    Select Create Claim

New Claim form with estimated insurance and patient portions
The New Claim form

Warning:Review the calculation against the insurer’s policy and bill before selecting Create Claim.

Note:Creating a claim records it in EliteHMS; it does not submit it to the insurer. Follow the panel’s submission method and update the claim status when you receive a response.

Track a claim

In the Claims tab, search by claim number, patient, or bill; filter by panel or status; and select Update Status to record progress:

  • Draft: Claim record created.
  • Submitted: Sent to the insurer or panel.
  • Under Review: Waiting for the insurer’s decision.
  • Approved or Partially Approved: The insurer approved all or part of the claim.
  • Rejected: The insurer declined it.
  • Appealed: A challenge or appeal has been recorded.
  • Paid: Payment received and recorded.
Claims tab with search, filters, and the Update Status button
The Claims tab

When updating a claim, record the approved amount, amount received, insurer’s reference number, cheque or transfer number, and notes as applicable.

Note:Only draft claims can be deleted.

Reports

Open the Report tab to review totals claimed, approved, paid, and pending payment; panel performance; and claims grouped by status.

Report tab with panel performance and claims by status
The Report tab

Note:These totals depend on claim records and statuses entered in the system.

Short definitions

  • Panel: An insurer, employer, or program that may cover eligible patient costs.
  • Coverage percentage: The share of eligible costs assigned to insurance under the panel settings.
  • Co-pay: The share assigned to the patient under those settings.
  • Pre-authorization: Approval requested from the insurer before providing certain services.
  • Claim: A request for reimbursement or payment sent to an insurer or panel.
  • Outstanding: The approved amount that has not yet been recorded as paid.
  • TPA: Third-party administrator; an organization that manages insurance claims for an insurer or employer.