Policies in Careswitch define the rules for how a client's care is covered and billed. A Policy tells Careswitch who is paying, which services are covered, how much care is available, and how long the coverage is valid.
An active Policy is required for a client's care to be billed.
Think of a Policy as the set of billing and coverage instructions for a client. It tells Careswitch what services can be billed, how much care is available, when the coverage applies, and who is responsible for payment.
What information does a Policy include?
A Policy brings together the information Careswitch needs to determine whether care can be billed. Depending on the type of Policy, this may include:
Payer: Who is responsible for paying for the care.
Services: The services covered by the Policy.
Limits: The amount of care authorized, such as hours, visits, or dollars.
Coverage dates: When the Policy begins and ends.
Rates: The rate used for billing.
Authorization information: Details such as an authorization number for third-party coverage.
Careswitch uses this information in the background when scheduling, tracking service usage, and billing.
Two Types of Policies
Private-Pay Policies
A Private-Pay Policy is used when the client or their family pays directly for care.
When you create a Private-Pay Policy, you enter the Policy details yourself, including:
Start and end dates
Services
Billing rate
Other applicable Policy information
Private-Pay Policies become active immediately after they are created. They do not require an authorization document or review.
Related article: How to Create a Private-Pay Policy
Third-Party (Insurance) Policies
A Third-Party Policy is used when an outside organization is responsible for paying for the client's care, such as the VA, Medicaid, a managed care organization, or another insurance plan.
Third-Party Policies are created from an authorization document provided by the payer. When you upload the document, Careswitch uses AI to extract the relevant information and create the Policy.
The Policy then goes through a review process before it becomes active:
Upload the authorization document.
Careswitch processes the document and extracts the Policy information.
Paradigm reviews the extracted information.
Once approved, the Policy becomes active and can be used for billing.
The review step is important because insurance authorizations are legally binding documents. A member of the team reviews the information extracted by AI to verify that key details, such as service limits and coverage dates, are accurate before the policy is used for billing.
Related article: How to Create a Third-Party Policy
Service Groups
A Policy can contain one or more Service Groups. Each Service Group represents a specific set of authorized services and has its own limits and status.
For example, a client's authorization might include:
Personal Care: 20 hours per week through September 30, 2027
Respite Care: 40 hours per quarter through September 30, 2027
Each Service Group tracks its usage separately. Using hours from one Service Group does not reduce the available amount in another.
Service Groups can also be managed individually. For example, if Respite Care is no longer authorized but Personal Care remains active, the Respite Service Group can be made inactive while the Personal Care Service Group remains active.
Policy statuses
A Policy's status tells you where it is in the process and whether it can currently be used for billing.
Status | What it means |
Processing | Careswitch is processing the uploaded authorization document and extracting information from it. |
Pending | The extracted information is being reviewed by Paradigm staff. |
Active | The Policy is active and can be used for scheduling and billing. |
Partially Active | Some Service Groups are active while others have expired or been made inactive. The active Service Groups can still be used for billing. |
Inactive | All Service Groups are inactive or have expired. The Policy cannot be used for new billable care. |
Rejected | The Policy could not be approved. A reason for the rejection will be provided so you can correct the issue and resubmit it, when applicable. |
Archived | The Policy was manually archived and is retained for historical records. |
How policies work in Careswitch
Once a Policy is set up, Careswitch uses it throughout the scheduling and billing process.
When you schedule a shift: Careswitch checks the client's active Policies and uses the appropriate Policy based on the service being provided.
When a shift is completed: The completed care is counted toward the applicable Service Group's authorized limit.
When you're approaching a limit: Careswitch can provide warnings when a Service Group is getting close to its authorized limit, helping you identify potential coverage issues before the limit is reached.
When you bill or submit claims: Careswitch uses the Policy information, such as the payer, authorization details, and applicable rates, to help generate the appropriate billing information or claim.
Where to find Policies
You can view Policies from either a client's profile or a third-party payer's profile.
From a client profile
Open the client's profile and select the Policies tab.
From a third-party payer
Go to Payers → Third-Party Payer → Policies to view Policies associated with that payer. This is useful when you need to see Policies for multiple clients covered by the same payer.
What's next?
Now that you understand how Policies work, use the appropriate guide to create the type of Policy you need: