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Eligibility Check Section

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Select the eligibility validation method, status, and status reasons for each funding source.

  • The authorization record will be set to the status defined.

  • The authorization status reason will be set to the status reason defined.

Prerequisites:

  1. In the Eligibility Validation Method field, select the method of validation.

  2. In the Eligibility Check Failed field, select the reason.

  3. In the Authorization Status field, select the status for the authorization.

  4. In the Authorization Status Reason field, select the reason.

  5. In the Claim Status field, select the status for the claim.

  6. In the Claim Status Reason field, select the reason.

  7. In the Additional Eligibility Checks field, select the additional checks to perform on financial eligibility records.
    This field is only enabled if the Eligibility Validation Method is set to Validate via Financial Eligibility Record.

    • Missing Subscriber Policy Number - Includes any authorizations/services for clients without a Subscriber Policy # value filed in the Financial Eligibility record for applicable guarantor(s) in the connected myAvatar PM/Cal-PM system.

    • Missing Subscriber Client Index Number - Includes any authorizations/services for clients without a Subscriber Client Index Number value filed in the Financial Eligibility record for applicable guarantor(s) in the connected myAvatar Cal-PM system.
      The Subscriber Client Index Number field exists in myAvatar Cal-PM only; accordingly, this selection should only be used in cases where myAvatar Cal-PM is the parent system.

    • Unverified Eligibility - Includes any authorizations/services for clients where the Eligibility Verified field is set to No in the Financial Eligibility record for applicable guarantor(s) in the connected myAvatar PM/Cal-PM system.

    • Missing Subscriber Date of Birth - Include any authorizations/services for clients without a Subscriber's Date of Birth value filed in the Financial Eligibility record for applicable guarantor(s) in the connected myAvatar PM/Cal-PM system.

    • Missing Subscriber Address Information - Includes any authorizations/services for clients without Subscriber Address - Street, Subscriber Address - Zip Code, Subscriber Address - City, and/or Subscriber Address - State values filed in the Financial Eligibility record for applicable guarantor(s) in the connected myAvatar PM/Cal-PM system.

    • Missing Admitting Diagnosis - The three Missing Admitting Diagnosis fields (ProviderConnect Batch Origin, 837 Batch Origin, and MSO Batch Origin) include any authorizations/services for clients without an admitting diagnosis value filed in the connected myAvatar PM or Cal-PM system.

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SQL Table

  • SYSTEM.fund_src_elig_check_type