Go to Rules page and click '+ New Rule'
ALLOCATE and LIMIT
Below is a detailed explanation of each function.
a. Participant
Select the participant from the dropdown list. Once chosen, the participant’s details will be linked to the rule you’re creating.
b. Provider
Choose the provider you’d like the rule to apply to.
c. View Budget & Participant Profile
Quick access buttons that allow you to:
View Budget: See the participant’s current budget.
View Participant: Open the participant’s profile directly.
d. Date of Birth
Automatically displays the participant’s date of birth once they are selected.
e. Service Agreements / Budget Rules
Choose whether you are creating a Service Agreement or setting Budget Rules. In this article we will explain the Allocate and Limit under Service Agreement.
f. Allocate vs. Limit
Select whether the rule is an Allocation or a Limit:
Allocation: works more like a service booking. It sets aside a portion of the participant’s budget for a specific provider, but it doesn’t act as a hard restriction. Even if the allocated amount is reached, the provider can still continue to submit claims. Allocation rules are useful when you simply want to earmark funds without enforcing a strict limit.
Limit: is used when you want to restrict a provider to using only a specific amount from a participant’s budget. This acts as a hard cap, once the limit is reached, the provider is no longer able to claim beyond that amount. Limit rules are ideal when you want to strictly control the maximum budget a provider can access
g. Filter Level
Choose whether to apply the rule at a Category level or an Item level.
h. Support Category
Select the budget category the rule should apply to.
i. Effective Date / Expiry Date
Effective Date: The start date for the rule.
Expiry Date: The end date for the rule.
By default, these dates will match the participant’s current plan, but you can adjust as needed.
j. Amount
Enter the budget amount for this rule. The system will also show the remaining balance for the chosen category or item.
k. Matching Invoices
Displays the total value of any invoices already in Caresquare (CS) that match the provider and category/item selected.
l. Description
Optional field where you can add notes or a description for the rule.
m. File Attachment
Upload and attach any relevant files (e.g., service agreement documents).
n. Budget Breakdown & Calculations
This section gives you a real-time breakdown of budgets:
Total Budget: The total budget available for the chosen category/item.
Budget Remaining: Funds left after current and previous rules.
Other Agreements: Amounts already tied to existing rules.
This Rule: The amount allocated or limited by the current rule.
Remaining: The balance remaining after this rule is applied.
o. Other Service Agreements
Lists any other rules that have already been created for the same category/item, including details such as provider, effective dates, and status.
p. Current Matching Invoices
Displays invoices already uploaded in CS under the selected provider, including details such as invoice date, number, service period, item numbers, quantity, unit price, and total price.
q. Invoices Tools
Use the toolbar to:
Filter results
Download invoices
Refresh the invoice list
r. Create
Once all details are completed, click Create to save and activate the rule.
Create Rule – Sample Walkthrough (ALLOCATE)
In this example, we are creating a Limit Rule for participant Mykala Portillo with provider ABC Sample Company. Here’s how each section works:
🔹 Key Fields Explained with Your Example (Allocate)
1. Participant & Provider
Participant: Mykala Portillo
Provider: AEP Health Group
➡ This allocation rule applies only to AEP Health Group services for Mykala.
2. Filter Level & Support Category
Filter Level: Category
Support Category: Assistive Technology
➡ The allocation only applies to Mykala’s Assistive Technology budget.
3. Effective & Expiry Dates
Effective Date: 01 Feb 2024
Expiry Date: 01 Feb 2026
➡ The allocation will be active for the full 2 years of Mykala’s plan.
4. Allocation Amount
Allocated: $250
➡ This earmarks $250 of Mykala’s Assistive Technology funds for AEP Health Group.
⚠️ Important: Because it’s an allocation, AEP Health Group can still submit invoices beyond $250 if needed. The allocation just sets aside funds for tracking.
5. Budget Snapshot
Total Budget: $1,500 (total Assistive Technology funding available)
Budget Remaining: $1,499.98 (before considering this allocation)
Other Agreements: $300 already allocated to Some Business (another provider)
This Rule: $250 now allocated to AEP Health Group
Remaining: $949.98 still available to be allocated to other providers or items
➡ This helps you see the full picture: total budget, what’s already allocated, and what’s left.
6. Other Service Agreements
Some Business has an allocation of $300, effective from 01 Feb 2024 to 01 Feb 2026.
➡ You can see how the new allocation interacts with existing ones.
7. Matching Invoices
Currently: $0.00 (no invoices yet from AEP Health Group under Assistive Technology).
➡ When AEP Health Group invoices come in, they’ll automatically match this allocation.
✅ In summary:
For participant Mykala Portillo, we’ve allocated $250 from her Assistive Technology budget ($1,500 total) to AEP Health Group. She also has another allocation of $300 with Some Business. After both allocations, Mykala still has $949.98 in Assistive Technology funds available.
Because this is an allocation, AEP Health Group can still submit invoices over $250, the allocation is simply a way to set aside funds for tracking and planning. The system cross-checks invoices, other agreements, and budget balances automatically to help ensure accuracy.