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Benefit Plans - PM

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Maintain myAvatar benefit plans. Benefit plans are used by the financial eligibility forms (Guarantor Selection section) to assign plans to guarantors.

  1. Go to: Avatar PM > System Maintenance > System Definition > Benefit Plans
  2. In the Plan Name/ID # field, enter the benefit plan name, and click Select Plan Name to perform a search.

    • If a plan by that name does not already exist, click New.

    • Select whether or not to automatically assign the next ID number to the plan. When No is selected, you will have the option to provide a unique plan number.

  3. In the Benefit Plan field, enter the plan name.
  4. In the Plan Type field, select Contract Plan, or Non Contract Plan.
  5. Click Display Plans to generate a report that displays myAvatar benefit plan information entered in this form.

Insurance Plan Levels

In this section you will define information that will populate financial eligibility forms, and will be used in the liability distribution process. In financial eligibility forms, the benefit plan information can be edited to meet a client’s requirements.

  1. In the Insurance Plan Levels table, click Add New Item.
  2. The Level Number field shows the next available level number.
  3. In the Level Start Date field, enter the benefit plan level start date. Services are applied after this date.
  4. Provide a Description of the level.
  5. In the Level End Date field, enter the benefit plan level end date. Services are applied after this date. If no benefit levels are available, liability is not applied for the guarantor.
  6. In the Deductible Type field, select the type of deductible. This field is required if a deductible applies to the benefit plan level.
  7. In the Deductible Amount field, enter the deductible amount. This field is required if a deductible applies to the benefit plan level.
  8. In the Per Diem Rate field, enter the per diem rate. This field is required for contract plans.
  9. In the Per Diem Percentage field, enter the per diem percentage charge covered in the benefit plan level. This field is required for contract plans.
  10. In the Covered Charge Categories field, select the insurance charge categories to be included in the benefit plan level.
  11. In the Insurance Dollar Limit field, enter the total dollar amount.
  12. In the Insurance Dollar Limit Per Day field, enter the maximum daily dollar amount covered. This is used for non-contract plans.
    Note: If the amount in any of the following fields is exceeded, the next benefit plan level is evaluated.
  13. In the Maximum Covered Days field, enter the maximum number of service days covered. This field is used for non-contract plans.
  14. In the Maximum Covered Partial Days field, enter the maximum number of days covered. This value is the maximum number of applied partial hospitalization days.
  15. In the Maximum Covered Ancillary Charges field, enter the maximum dollar amount for ancillary charges. This value is the service fee applied for ancillary/other charges.
  16. In the Maximum Covered Visits field, enter the maximum number of service visits. This value is the maximum number of services defined as visits in the Service Codes form.
  17. In the Monthly Maximum Responsibility field, enter the maximum dollar amount per month.
  18. In the Maximum Units Per Day field, enter the maximum number of service units for a single day (used for contract plans). This value is the number of service units applied to the benefit plan level in one day.
  19. In the Insurance Dollar Limit RB Per Day — Enter the room and board maximum dollar per day amount charged to the guarantor for this plan level. If the amount is exceeded, the next level is evaluated for the remainder.
  20. In the Percentage of Coverage field, enter the percentage of the total charge covered.
    • The service fee is multiplied by this percentage for the amount of charge covered by the guarantor.
    • Any remainder is evaluated by the next guarantor.
    • Used for non-contract plans.
  21. In the Maximum Amount Per Service field, enter the maximum service charge amount. (used for non-contract plans). Any additional remaining liability is evaluated by the next guarantor.
  22. In the Practitioner Categories Necessary For Coverage field, select the practitioner categories authorized to provide services. If a practitioner is associated with the charge categories, the service charge will be evaluated by the next benefit plan level.
  23. If there is a sliding fee scale, select the appropriate value from the Sliding Fee Scale field.
  24. In the Program Association field, select the programs to associate to the benefit plan. Liability distribution will leverage this field, against the service program to select benefit plans.
  25. Click Submit.
► Registry Settings
► Registry Settings - Cal-PM
► SQL Tables
  • SYSTEM.billing_plan_table
  • SYSTEM.billing_plan_table_levels