How to Create a Pricing Rule for Insurance Coverage

How to Create a Pricing Rule for Insurance Coverage

This article explains the steps to create a Pricing Rule for Insurance Coverage in Ksatria eHospital.
Pricing rules determine how much of a service cost will be covered based on the selected insurance provider, plan, and other patient-related criteria.

Step 1: Create the Insurance Provider and Insurance Plan


  1. Go to the Claim module.

  2. Create a new Insurance Provider and the corresponding Insurance Plan.
    These will be used later when setting up the pricing rule.

Step 2: Open the Pricing Rule Setup


  1. Go to Tariff Management.

  2. Select Pricing Rule.

  3. Click Create New Rule to add a new pricing rule for coverage.

Step 3: Enter Basic Pricing Rule Information


Fill in the following fields:

  • Pricing Rule Code: Enter a unique code for the rule.

  • Pricing Rule Name: Enter a descriptive name for the rule.

  • Apply As: Select Coverage (this defines that the rule is for insurance coverage).

  • Apply to Price Scheme: Choose the price scheme that the coverage should be based on.

Example:

  • If you select Base Price, the coverage will match the amount defined in the Base Price.

  • If you select VIP Price, the coverage will follow the amount defined in the VIP Price.

You can set or edit the price schemes from Tariff Management → Tariff Definition.

Step 4: Add Description and Priority

  • Description: Add a note or explanation for this pricing rule (optional but recommended).

  • Priority: Choose Low, Medium, or High.

Note:
Priority determines which rule is applied if multiple pricing rules match the same criteria.
The rule with the higher priority will take effect.

Step 5: Set the Pricing Rule Criteria


Define the conditions under which this pricing rule will apply.
You can set one or more of the following criteria:

  1. Patient Type – Select which patient type this rule applies to.

  2. Payment Type – Choose which payment type the rule applies to.

  3. Provider Name – Select the insurance provider created earlier.

  4. Provider Plan – Choose the specific insurance plan.

  5. Treatment Class – Define which treatment class the rule should apply to.

You can add multiple criteria for one pricing rule.
This means the rule will be applied only if all selected criteria are met during patient registration.

Step 6: Save and Test the Rule

  1. After entering all required information and criteria, click Save.

  2. To test the rule:

    • Register a patient that meets all criteria you defined.

    • When the Invoice is generated, the system will automatically calculate the coverage based on the selected price scheme.

✅ You’ve successfully created a Pricing Rule for Insurance Coverage!
The system will now apply this rule automatically for patients who meet the defined criteria.

    • Related Articles

    • How to Manage Insurance Plan

      This article explains how to create, search, and edit insurance plans in the Claim Module of Ksatria eHospital. Create Insurance Plan Purpose To register a new insurance plan under an existing insurance provider, including plan-specific coverage ...

    • How to Manage Insurance Provider

      This article covers how to create and search insurance providers in the Claim Module of Ksatria eHospital. Create Insurance Provider Purpose To register a new insurance provider into the system, including both private insurers and company-sponsored ...

    • How To Create new Catalogue Item

      The process of creating a new Catalogue consists of three pages: Create Catalogue UOM Details (optional) Initial Warehouse (optional) Note: UOM Details and Initial Warehouse are not mandatory, but should be completed if the catalogue will be managed ...

    • Room Management

      1. Create Room Login to the Ksatria eHospital system. Click the Bed Management module icon. Click Create+ to open the Create Room page. Fill in the required information in two sections: General Information: Room number, name, case, gender allocation, ...

    • Bed Management

      1. Create Bed Login to the system. Open the Bed Management module → click Bed in the sidebar. Click Create+. Fill in required information: Bed No, Bed Name, Treatment Class, Room, Location, Availability, Active, and Notes. Required fields are marked ...