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Plan Definition - MSO

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Use the Plan Definition form in myAvatar MSO to define services that are covered by a funding source.

  • A funding source can be assigned to multiple plans.
  • A plan can be assigned to a single funding source.
  • Plans are assigned to members through the Member Enrollment form.
  • If appropriate, service availability can be adjudicated through the Manual Batch Adjudication form (open batches), and Retro Claim Adjudication form (closed batches).
  1. Search for Plan Definition or go to Avatar MSO > Funding Source Management > Plan Definition.
  2. Within Select Plan, search for the benefit plan by name or ID. The results dynamically appear below the search bar.
  3. If a benefit plan is found, select the benefit plan and OK.
    • If a benefit plan is not found, select New Plan.
    • The Auto Assign Next ID Number dialog displays.
    • Choose Yes to generate a benefit plan ID, or choose No to display the ID Number dialog and enter an ID.
  4. In the Benefit Plan Name field, enter the plan name, beginning with an uppercase letter.
  5. In the Funding Source field, select the funding source.
    Note: Each funding source can have multiple plans associated with it, but a benefit plan can only be associated with one funding source and the selection cannot be changed once submitted.
  6. In the Does This Plan Have a P.O.S. Option field:
    • Select Yes if the out of network provider has a POS (place of service) form.
    • Select No if the provider does not have a POS form.
    • If a member receives a service from a out of network provider, and the plan does not have a POS form, services will be denied.
  7. In the Date Plan Offered Effective Date field, enter the plan effective date.
    • Claims for services before this date will be denied.
  8. In the Date Plan Offered Expiration Date field, enter the plan expiration date.
    • Claims for services after this date will be denied.
    • The following fields define maximum plan liability limits and the overall liability limits of plan coverage. These limits should be equal to or greater than limits for a plan level. Benefit plan limits cannot be exceeded by any combination of plan levels.
  9. In the Lifetime fields, define the highest amounts for the duration of a plan.
  10. In the Annual fields, define annual amounts for the plan.
  11. In the Lifetime Maximum fields, define lifetime benefit amounts.
  12. When finished, select Submit.

Note: The Lifetime and Annual fields can be overridden for the benefit plan in the Approve/Pend/Deny Rules Definition form.

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