Bill part of a sale to a patient's HMO (health insurer) and collect only the co-pay from the patient. The HMO-covered amount becomes a receivable you batch into a claim, submit to the HMO, and reconcile when they pay.
Set up HMOs
- Open Pharmacy → HMOs / Insurers → New HMO.
- Enter the HMO's name, optional code, contact details, and a default coverage % (the share of a bill the HMO usually covers).
- Save. Repeat for each insurer you deal with.
Record a patient's membership
On a saved prescription (Pharmacy → Prescriptions), the Details tab shows an HMO / insurance box once a patient is selected:
- Choose the patient's Insurer.
- Enter their Membership no. and Coverage % (this pre-fills from the HMO's default — change it if this patient's plan differs).
- Click Save HMO.
This is saved on the patient's record, so it applies to every future sale — you only enter it once. (Choosing Not insured clears the membership.)
Sell with co-pay
- Ring up the sale (or use Bill / Dispense from the prescription) and pick the patient as the customer.
- If the patient has an HMO on file, the HMO (co-pay) and HMO covers fields fill in automatically from their membership — the line under them shows "Patient pays ≈ … · HMO billed …". You can still change the insurer or the covered amount by hand (a manual change takes over from the auto-fill).
- Take only the co-pay (the Patient pays figure) from the patient as the normal tender. The HMO-covered amount stays as a receivable to be claimed.
Build & submit a claim
- Open Pharmacy → HMO Claims → New claim.
- Pick the HMO. The grid lists that HMO's covered sales not yet claimed.
- Tick the sales to include, then Create claim (status Draft).
- Open the claim and Submit it when you send it to the HMO.
- Send the claim to the HMO:
- Export CSV — a spreadsheet of the covered invoices (invoice #, patient, membership no., billed/approved, status).
- Export PDF — a print-ready claim sheet on your pharmacy letterhead.
- Email HMO — emails the PDF straight to the HMO. It goes out from your pharmacy's name with replies coming back to your email on file, so the HMO sees you as the sender. Leave the address blank to use the HMO's email on record, or type a different one; add an optional note.
Reconcile the approval
- Open the submitted claim.
- For each line, enter the Approved amount and set its status (Approved / Rejected).
- Save reconciliation. This records what the HMO approved — the claim total updates and it stays Submitted (awaiting payment), or Rejected if nothing was approved. No cash is posted yet.
Handle any rejected amount
If the HMO approved less than billed, the shortfall is still sitting on the HMO's account. Click Resolve rejections and choose:
- Re-bill the patients — each rejected amount moves back to the patient it belonged to; they now owe it (it reappears on their balance).
- Write it off — absorb the shortfall as an expense; pick the write-off account (a bad-debt/expense GL account).
Either way, the un-approved amount is cleared off the HMO's receivable. You can only resolve a claim's rejections once.
Record the payment when the money arrives
- Open the claim and click Record payment.
- Enter the Amount received (defaults to the approved total), the Deposit account (the cash/bank account the money landed in), and the Payment method; add a Reference if you have one.
- Record payment. This posts a receipt against the HMO's account (Dr cash/bank · Cr the HMO's receivable) — clearing the balance the covered sales built up — and marks the claim Paid (or PartiallyPaid if the HMO paid less than approved).
Tips
- A sale can only be on one claim — once claimed it drops off the "unclaimed" list.
- Reconcile promptly so your HMO receivables reflect what's actually been paid.
Common problems
- A sale isn't in the unclaimed list. → It needs an HMO and a covered amount > 0 on the sale, and must not already be on a claim.
- "None of the selected invoices are claimable." → They belong to a different HMO, have no coverage, or are already claimed.
- Can't delete a claim. → Settled (Paid/PartiallyPaid) claims are locked; reconcile-correct instead.
- I can't open HMOs / Claims. → You need the Medical Resources permission.