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Client Other Healthcare Coverage form

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The Client Other Healthcare Coverage form captures Other Subscriber Information to be included in outbound 837 claim files.  This form is available within myAvatar Cal-PM and ProviderConnect NX.

Prerequisites:

  • Prior to installing necessary updates for the Client Other Healthcare Coverage enhancements in a production environment, Netsmart strongly recommends installing the updates and performing thorough testing in a test environment.
  • The Client Other Healthcare Coverage functionality was added to myAvatar Cal-PM in Avatar Cal-PM 2022 Update 14. Support for this form to be accessed by a ProviderConnect NX end user was added in Avatar ProviderConnect NX 2022 Update 1.
  • Registry Setting Add Support For Client Other Healthcare Coverage is enabled
  • Registry Setting Add Support For The Input Of Third Party Payer Amounts is set to ‘2’
  • Client is actively admitted to a contracting provider program
  • Client has services covered under an active authorization
  • Contracting Provider is not submitting electronic claim files and claims are submitted through one of the following methods:
    • Contracting Provider entering services into claim processing forms ProviderConnect NX;
    • Managing Organization is entering services into MSO claim processing forms on behalf of the Contracting Provider
  1. A contracting provider will access ProviderConnect NX and complete the Client Other Healthcare Coverage fields to capture payer information and subscriber data.
  2. After a contracting provider has rendered a service, if they cannot submit an 837 file to the Managing Organization, they will need to access ProviderConnect NX and enter the service data within the Fast Service Entry Submission form.
  3. The contracting provider accesses the Enter Third Party Adjudication Data grid to input additional information for the service related to the primary payer’s adjudication of the service. This includes entry of the Payer Identifier. In order for the third party adjudication data to generate on an outbound claim from the parent system, the identifier entered here must match the Guarantor Payer Identifier entered in the Client Other Healthcare Coverage form.

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  4. After selecting the View button, another grid will display to input the CAS segments applied by the primary payer when the service was initially adjudicated. The CAS segments entered here will be included in the service line adjudication detail (2430) of an outbound claim.

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  5. Once all service information is entered, a batch can be created and closed.

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  6. In the myAvatar Client Ledger, when the service is approved and pushed to the parent system, the third party allowed amount will be pushed as the charge amount. There is also an asterisk applied to the guarantor number to alert the end user that this service was generated in myAvatar MSO and has third party adjudication data tied to it.

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