Client Other Healthcare Coverage form fields

Create or Edit Coverage Period

• This is a required field
• The options in the dropdown are:
  • Select “Create New” to create a new record; or
  • Select an existing record to edit

Guarantor #

• This is a required field
• Search for an active Guarantor by name or ID
  • Search results will include active Guarantors as defined in Guarantors/Payors

Guarantor Name

• This is a required field
• The Guarantor Name will default based upon what is configured in Guarantors/Payors
• This field may be edited

Effective Date

• This is a required field
• Enter the effective date of the client’s healthcare coverage with the selected Guarantor

Expiration Date

• This is an optional field
• Enter the expiration date of the client’s healthcare coverage with the selected Guarantor, if known

Client’s Relationship To Subscriber

• This is a required field
• Select the Client’s relationship to subscriber from the dropdown
• This is a user-defined dictionary. Configuration:
  • Dictionary File: Client
  • Number: 3106
  • This dictionary is pre-populated with HIPAA allowable codes and values
• If ‘Self’ is selected in this field, several fields will populate with the client’s current demographics.
  • Note: If the registry setting ‘Update Financial Eligibility Data’ is enabled, the client information in this form will update when the client’s demographic record is updated at admission, discharge or ‘Update Client Data’.  

Subscriber’s Name

• This is a required field
• Enter the Subscriber’s Name
• If ‘Client’s Relationship to Subscriber’ is ‘Self’, this field will populate with the client’s current demographics

Subscriber Address – Street Line 1

• This is an optional field
• Enter the Subscriber’s Address
• If ‘Client’s Relationship to Subscriber’ is ‘Self’, this field will populate with the client’s current demographics
• Note: Subscriber address fields are collected for informational purposes only and will not be included on an outbound 837. 2330A*N3 and 2330*N4 segments are suppressed when the ‘Support MSO Other Healthcare Coverage’ setting is enabled and the claim is being added to a Cal-PM/PM outbound 837 claim file.

Subscriber Address – Street Line 2

• This is an optional field
• Enter the Subscriber’s Address
• If ‘Client’s Relationship to Subscriber’ is ‘Self’, this field will populate with the client’s current demographics

Subscriber Address – City

• This is an optional field
• Enter the Subscriber’s Address - City
• If ‘Client’s Relationship to Subscriber’ is ‘Self’, this field will populate with the client’s current demographics

Subscriber Address – State

• This is an optional field
• Select the Subscriber’s Address - State
• If ‘Client’s Relationship to Subscriber’ is ‘Self’, this field will populate with the client’s current demographics

Subscriber Address – Zip

• This is an optional field
• Enter the Subscriber’s Address - Zip
• If ‘Client’s Relationship to Subscriber’ is ‘Self’, this field will populate with the client’s current demographics

Subscriber Policy #

• This is a required field
• Enter the Subscriber’s Policy Number for the selected Guarantor

Subscriber Group Name

• This is an optional field
• Enter the Subscriber Group Name

Subscriber Assignment Of Benefits

• This is a required field
• Select from the single select dictionary. Options are:
  • Yes
  • No
  • Refused

Subscriber Release Of Info

• This is a required field
• Select from the single select dictionary. Options are:
  • Yes
  • No

Guarantor Payer Identifier

• This is a required field
• Enter the Guarantor’s Payer Identifier
• To have third party adjudication data reported on an outbound 837 Institutional or Professional file, the Guarantor Payer Identifier entered here must match the ‘Payer Identifier’ entered for the service in the ‘Enter Third Party Adjudication Data’ section in the myAvatar MSO Claim Processing and Fast Service Entry forms.

Insurance Type Code (232-SBR-05)

• This is an optional field
• Select an ‘Insurance Type Code’ from the list
  • If the ‘Insurance Type Code – Other Insurance Info (2320-SBR-05)’ is completed as part of the selected Guarantor’s Guarantor/Payors record, it will default in this form. The end user will be allowed to edit the selection

Claim Filing Indicator Code (2320-SBR-09)

• This is an optional field
• Select an ‘Claim Filing Indicator Code’ from the list
  • If the ‘Claim Filing Indicator Code (2000B/2320-SBR-09)’ field’ is completed as part of the selected Guarantor’s Guarantor/Payors record, it will default in this form. The end user will be allowed to edit the selection