Guarantor Selection Section - PM

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Select the guarantor and enter guarantor and subscriber information. The Guarantor Selection section appears in the Financial Eligibility and Cross Episode Financial Eligibility forms.

The Default Client Demographic Information extended dictionary controls whether client demographic information entered in the Update Client Data form populates the demographic fields in this form.
The Subscriber Client Index Number field is added to the form with the installation of the myAvatar LA Provider Integration module.

Go to the Financial Eligibility form or the Cross Episode Financial Eligibility form.
In the Guarantor Information table, click Add New Item.
In the Guarantor # field, enter the guarantor number, and select.
In the Guarantor Name field, edit the guarantor name if appropriate.
For the Guarantor Plan field, select the benefit plan. This field will default if set up to do so in the Guarantors/Payors form.
In the Customize Guarantor Plan field:
- Select Yes to customize the benefit plan. Yes is available in this field if Yes is selected in the Allow Customization Of Guarantor Plan field (Guarantors/Payors form).
  OR
- Select No to use the default benefit plan information.
In the Address and Phone Number fields, enter the guarantor’s street address, city, state, ZIP code, and phone number.
For the Inhibit Billing By Mail field, select Yes to prevent a patient mailing address from appearing on the standard self pay statement.
In the Is This A Managed Care Contract field, select Yes for managed care contracts, or No for all other contracts. This is a reporting-only field only.
In the Effective Date Of Contract and Expiration Date of Contract fields, enter the first and last date that guarantor liability can be distributed.
In the Insurance Code/Medicaid Tape field, enter the insurance code for the Medicaid tape.
For the Eligibility Verified field, select Yes if client eligibility has been verified.
Note: For liability distribution, if you select No, liability distributes on the client ledger and is not included in an interim billing batch.
In the Coverage Effective Date, enter the first coverage date.
Liability Distribution - Service liability posted after this date is distributed to the guarantor.
In the Coverage Expiration Date field, enter the last coverage date.
For the Client’s Relationship To Subscriber field, select the relation.
In the Subscriber's Name, Address, Zipcode, City, State and Phone Number fields, enter demographic information as appropriate.
In the Subscriber Address - County field, select the county.
In the Subscriber's Social Security #, Subscriber's Birth Date, and Subscriber Sex fields, enter demographic information as appropriate.
Note: Access to the Social Security Number field is defined by a system administrator in the User Definition and User Role Definition forms (Social Security Number Access field). The user may be able to:
- Enter new client data, edit data, and view data.
- Enter new client data and view data.
- Enter new client data.
In the Subscriber Military Status field, select the subscriber's military status.
In the Subscriber Branch/Service field, select the subscriber's military service.
In the Subscriber’s Employment Status field, select the employment status.
For the Subscriber Employee ID # and Subscriber Employer Name, ID Number, and Address fields, enter demographic information as appropriate.
In the Subscriber Employer Add - County field, select the county.
In the Subscriber Group Name and Group # fields, enter the group information.
In the Subscriber Policy # field, enter the subscriber policy number. The policy number is required for electronic billing.
This field can be required via the Financial Class dictionary, extended element Require Policy # For This Financial Class?
In the Subscriber Policy # Suffix field, enter the last two digits of the policy number.
In the Subscriber Medicare # and Medicaid # fields, enter the subscriber Medicare and Medicaid numbers.
In the Subscriber Treatment Auth. field, select Yes if the subscriber is authorized for treatment.
In the Subscriber Assignment Of Benefits field, select Yes if the subscriber has authorized payments to be sent directly to the provider.
In the Coordination Of Benefits field, select Yes if benefits are synchronized between multiple guarantors in a client’s financial eligibility.
In the Date Of Accident field, enter the accident date if applicable.
In the Date Benefits Terminated field, enter the termination date if applicable. This field does not affect liability distribution.
In the Date Benefits Denied field, enter the denial date if applicable. This field does not affect liability distribution.
In the Denial Code field, select the code.
In the Subscriber’s Covered Days field, enter the maximum number of room and board days that can be charged to the guarantor, for all levels of the plan. This number overwrites the benefit plan, if less than the total dollars are entered for all plan levels.
In the Maximum Covered Dollars field, enter the maximum number of dollars that can be charged to the guarantor for all levels of the plan. This number overwrites the plan if it is less than the total dollars entered in all levels of the plan.
In the Number Of Days For Interim Billing field, enter the number interim billing days. This is the number of days that must elapse from the last batch bill date before the guarantor can be included in another interim billing batch. For agencies that do PPS billing, do not use this field as the 60-day threshold for billing as this is pre-set when PPS billing is enabled and configured properly. Netsmart recommends this field be left blank.
In the Lifetime Reserve Days field, enter the number of lifetime reserve days.
If applicable, in the Do Not Use 271/834 Eligibility Information Through This Date field, enter a date this patient/guarantor should not be included in the 271/834.
In the Insurance Plan Name Or Program Name (HCFA-1500 Form Locator 11-C), enter the insurance plan or program name information.
For the Notes field, enter notes about the client's eligibility.
In the Medigap Guarantor field, select if there is a Medigap guarantor.
In the Maintenance Reason Code (834-2000-INS-04) field, enter the reason code.
For the Eligibility Inquiry (270) Status field, Request Inquiry and None can be selected manually. The other selections are made by the system after a response is received.
The Eligibility Response (271) Reject Reason Code is system generated.
In the Subscriber Release Of Info field, select Yes if the subscriber releases client benefit information.
In the Subscriber's Policy # Suffix field, enter the two-digit suffix.
In the Subscriber's ID Card Issue Date field, enter the date.
In the Subscriber Additional Id Qualifier (270-2100C-REF-01) field, select the qualifier.
In the Subscriber Additional Id Identifier (270-2100C-REF-02) field, select the identifier.
In the Default Plan Start Date field, enter the start date.
In the Default Plan End Date, enter the end date.
If applicable, select Yes or No in the Create New Levels from Master Record of Benefit Plan field.
Select the Default and Edit Plan Levels button to edit the plan levels.
In the Patient Signature Source Code (2300-CLM-10 and 2320-OI-04) field, select the code. This field display is controlled via the Specify Patient Signature Source Code registry setting.
In the NCPDP Eligibility Verification (E1) Request Status field, select the status of the inquiry request.
The NCPDP Eligibility Verification (E1) Request Response field displays the received information.
In the Subscriber Race field, select the subscriber's race.
In the Subscriber Ethnicity field, select the subscriber's ethnicity.
In the Subscriber Marital Status field, select the subscriber's marital status.
After completing the Guarantor Selection section, go to the Customize Plan section or the Cross Episode Financial Eligibility section to select the order of the guarantor you entered.
Note: The Customize Plan section is only available when the Customize Guarantor Plan value is 'Yes'.
Select Submit.