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Claim Adjustment Group/Reason Code Definition - PM

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Manage myAvatar claim adjustment group and reason codes.

Avatar PM > System Maintenance > System Definition > Claim Adjustment Group/Reason Code Definition

  • Assign or delete reason codes to a payment or adjustment code for a financial class, guarantor, claim adjustment group code.

  • Specify a transfer code for a guarantor, claim adjustment group code, and claim adjustment reason code combination.

  • Define financial classes that should be excluded when determining the guarantor for remaining balance transfer.

  • Define financial class to start at when determining the guarantor for remaining balance transfer.

  • Identify guarantors to bypass with payment posted against it for the service being adjudicated.

  1. In the Add/Delete field:

  • Select Add to create a new claim adjustment group/reason code definition.
  • Select Delete to remove a claim adjustment group/reason code definition.

  1. In the Financial Class field, select the financial class.

  2. The Guarantor field populates with a list of guarantors that are associated with the financial class. Select the guarantor.

  3. In the Claim Adjustment Group Code field, select the claim adjustment group code.

  4. In the Claim Adjustment Reason Code(s) field, select the claim adjustment reason code or codes.

  5. In the Posting Code field, select the posting code. Posting codes are maintained in the Posting/Adjustment Codes Definition form.

  6. When deleting code definitions, click the Select Code(s) To Delete button.

  7. The Select Code(s) To Delete screen displays. Choose the codes, click Ok.

  8. Click Delete Code(s) to remove claim or adjustment code definitions from myAvatar PM.

  9. Click Print Code(s) to generate a report that details all code definitions in this form.

 

If a transfer posting code is selected in the Posting Code field, the following fields are enabled:

Transfer Guarantor Rules

  1. In the In case of a remaining balance field, choose the order the adjustment will be transferred to other guarantors:

  • Select Iterate through guarantors as defined in Financial Eligibility starting with the first guarantor to transfer liability using the guarantors defined in the client's financial eligibility forms.
  • Select Iterate through guarantors as defined in Financial Eligibility starting with the first guarantor subsequent to the guarantor being processed to transfer liability to the first guarantor defined in the client's financial eligibility forms, before transferring liability to the guarantor defined in this form.

  1. In the Should a guarantor with payment(s) posted field:

    • Select Yes to bypass a guarantor who has payments posted for the service.

    • Select No to include a guarantor who has payments posted for the service.

  2. In the If no guarantor found to transfer the remaining balance field, select Yes to transfer a remaining balance to the Default Payor (99999) if no guarantor is found in the client's financial eligibility.

  3. In the Start at the following financial class field, the guarantor associated with the financial class will be evaluated for liability transfer before other guarantors in the client's financial eligibility.

  4. In the Exclude the following financial class(es) field, select the financial classes.

  5. In the Exclude the following guarantor(s) field, configure your 835 postings by selecting the guarantors to skip when transferring the remaining balance. The values in this field are filtered based on the financial classes chosen in the previous field.

  6. When finished, click File Code(s).

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