Guarantors/Payors - PM

Use the Guarantors/Payors form to maintain guarantor information in myAvatar. The information entered here is used automatically when a guarantor is assigned to a client.

1. Go to Avatar PM > System Maintenance > System Definition > Guarantors/Payors.
2. In the Add New or Edit Existing Guarantor field, select Add to add a guarantor, or select Edit to edit an existing guarantor.
3. In the New Guarantor/Guarantor field:
   • If adding a guarantor, enter a numeric value as the guarantor code in the New Guarantor Code field. Netsmart recommends utilizing a numbering convention when defining guarantors. This will help end-users assign the appropriate payor order in Financial Eligibility. This can be used as a General Ledger mapping component.
   • If editing a guarantor, select the guarantor in the Guarantor Code field.
4. Select whether or not the guarantor should be inactive. Inactive Guarantors will not show up in searches. Inactive guarantors can still be referenced for reporting purposes in the tables.
5. In the Guarantor Name field, enter the name of the guarantor. This information will default with this name in Financial Eligibility; however, the name as it exists in the client's Financial Eligibility record is what will be printed on the paper/electronic bill (e.g., CMS 1500, UB-04, 837I, 837P, etc.).
6. In the Guarantor Name For Alpha Lookup field, enter the name used for guarantor lookup fields. In most instances, Netsmart recommends making the Guarantor Name For Alpha Lookup the same as the Guarantor Name field.
7. In the Guarantor’s Address fields, enter demographic information. A nine-digit ZIP code is recommended. While this isn't a requirement for billing purposes at present, adding this information may reduce the risk of future billing errors.
8. In the Financial Class field, select the guarantor's financial class. The Financial Class field is used to group guarantors as a payor type and is used for several financial reporting, billing, and administrative functions. The first 10 values of this dictionary are predefined and should not be altered. This can be used as a General Ledger mapping component. Financial Class determines what prints in Form Locator 1 on a CMS 1500 claim format.
9. In the Guarantor Nature field, select Contract Guarantor, or Non-Contract Guarantor. This identifies whether a guarantor supports a per-diem rate.
   Note: Guarantor Nature cannot be changed once this form is filed. The guarantor nature and plan type must match when they are assigned to a client in the financial eligibility forms. Netsmart recommends all payors be configured as contract other than Self Pay or Sliding-Fee-Scale guarantors.
10. In the Associated Plans field, select the benefit plan(s) that could be selected for the guarantor in Financial Eligibility based on the client's plan. This field limits the available benefit plans end-users can choose from when entering a guarantor in Financial Eligibility. This would prevent an end-user from assigning a commercial benefit plan when assigning a Medicaid payor in Financial Eligibility.
11. In the Guarantor Plan field, select the default benefit plan (set up in the Benefit Plans form). When assigning a guarantor in Financial Eligibility, the default plan will auto-populate in Financial Eligibility when the guarantor is selected. For further information, please reference the Benefit Plans article.
12. In the Allow Customization Of Guarantor Plan field:
    • Select Yes to allow the guarantor’s plan to be customized in financial eligibility forms. If an agency needs to track multiple benefit/coverage start and end dates, this must be marked as yes.
      • If Yes is selected, the Customize Plan field will be enabled and auto-populated as No in Financial Eligibility, Cross Episode Financial Eligibility, and/or Fast Financial Eligibility. The Customize Plan field will allow for Yes to be selected and allow the end-user to customize benefits/coverage in the Customize Plan section.
    • Select No to disable the Customize Guarantor Plan field in Financial Eligibility form.
      • If No is selected, the Customize Plan field will be disabled and auto-populated as No in Financial Eligibility, Cross Episode Financial Eligibility, and/or Fast Financial Eligibility.
13. In the Default 'Client's Relationship To Subscriber' In Financial Eligibility field, select the value to populate the Client’s Relationship To Subscriber field in the Financial Eligibility, and Cross Episode Financial Eligibility forms. This is traditionally set as Self for Medicaid, Medicare, Managed Medicaid, and Managed Medicare/Medicare Supplemental guarantors. This default value can be overridden in the appropriate Financial Eligibility form.
14. In the Number of Interim Billing Days For Guarantor 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. If a number is entered, this will default and can be overridden in Financial Eligibility. 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.
15. In the Is This A Managed Care Contract field, select Yes for managed care, or select No for all other contracts. This field is for information and reporting only.
16. In the External Reviewer fields, enter the relevant information for the external reviewer of guarantor claims processed. An External Reviewer is typically considered
17. In the Categories Available For Review field, select the covered charge categories.
18. The Insurance Company Number (NEIC) field would be used for the National Electronic Insurance Clearinghouse guarantor number, however, this field is now disconnected legacy functionality.
19. In the Update Client Data? field, select Yes to push updated demographic information to the subscriber demographic fields in the Financial Eligibility form for this guarantor.
    Note: This push only occurs when the Client Relationship to Subscriber in the Financial Eligibility form for this guarantor is set to Self. The fields that are updated include: Subscriber Name, Subscriber Address 1, Subscriber Address 2, Zip, City, State, Home Phone, Work Phone, Social Security Number, Date of Birth, Sex.
20. In the Net Charge Over-Ride field:
21. • Select Gross Charge to print the total service charge on the bill.
    • Select Maximum Amount to Distribute from Service Fee/Cross References - Guarantor Definitions to use the value of the Maximum Amount to Distribute field on the Guarantor Definitions section of the Service Fee/Cross Reference Maintenance form as the service charge for the selected guarantor in all bill formats.
    • Select Net Charge (Expected Liability) to print the service liability assigned to the guarantor.
    • Select Net Charge Less Contractual (Expected Liability Less Any Contractual Adjustments) to print the service charge, minus the contractual allowance.
22. In the Does This Guarantor Get Billed Under 3-Day Billing Rule? field, select whether or not this rule applies to the current guarantor. This can be used for Non-Contract guarantors.
23. In the Family Guarantor field, select Yes if the guarantor is a family guarantor.
24. In the Inhibit Billing if Practitioner is not Covered by this Guarantor field, select the types of practitioners to prevent billing for if the selected practitioner is not covered by the selected guarantor. This functionality works according to the selections made in the Guarantor Coverage section of the Practitioner Enrollment form. Services will not be billed for guarantors that are not defined for the selected practitioner.
    • Select Supervising Practitioner to inhibit the bill under the Supervising Practitioner.
    • The field Select Type Of Information To Include In Rendering Provider Name (2310B) in the Guarantor/Program Billing Defaults form should be set to Supervising Practitioner Based On Rendering Practitioner.
    • Select Rendering Practitioner to inhibit the bill under the Rendering Practitioner.
    • The field Select Type Of Information To Include In Rendering Provider Name (2310B) in the Guarantor/Program Billing Defaults form should be set to Rendering Practitioner.
    • Select Incident To Practitioner to inhibit the bill under the Incident-To Practitioner.
    • See Enable Incident-To Practitioner for related functionality.
25. Specify if the guarantor is a Bad Debt Guarantor.
26. In the Use 5010/ICD-10 HCFA-1500 Claim Form field, select Yes to print on the HCFA-1500.
27. In the Sort HCFA-1500 By Program Of Service? field, select Yes to sort the HCFA-1500 bill by program of service.
28. In the Physician Number Qualifying Code (UB-92 Record 80) field, select the value to populate record 80 of the UB-92 electronic bill.
29. In the Generate No-Pay ##0 Claims field, select Yes to generate No-Pay ##0 claims. Or choose to generate No-Pay ##0 claims for discharged clients only.
30. In the Inhibit Liability Distribution By field, select the conditions for which to inhibit the liability distribution.
31. In the Start Date To Use ICD-10 Format For Billing field, enter the date to begin using ICD-10 codes IF the start date for this guarantor ought to be different from the system-wide cutover date. This field overrules the system-wide cutover date for guarantors with this exception.
32. In the Use 'Claim Statement Period Start' Date As field, select Yes to use the claim statement period start date as the claim statement period end date, when a claim statement period end date is not found in the 835 file.
33. In the Does Guarantor Require Spend-Down? field, select Yes if the guarantor requires spend-down.
34. In the Include No-Pay ##0 Claims In Separate 837 File field, select whether or not No-Pay##0 claims generated for the same series of services as claims where liability is distributed to the guarantor are always sorted into a new, separate 837 institutional file, regardless of other file generation controls within the form. If No, claims will be sorted into the same 837 Institutional outbound file, according to the file generation control within the form.
35. In the Exclude Roll-up Services From 837 Billing Files field, select whether or not to exclude roll-up services from being included in 837 billing files for a specific guarantor.
36. In the Types of Service to Include In No-Pay ##0 Claims field, select the types of services that can be included on a no-pay claim instead of defaulting to Room + Board.
    Note: The client's financial eligibility plan must have the service charge category associated, or the guarantor will not be included.
37. When finished, click Process.

► Additional Sections

• Contractual Guarantor Information
• Authorization Information
• Guarantor Display Sorted By Financial Class
• 270 / 271 / 834
• 835
• Treatment Plan Requirements
• 837
• 278 Authorization Request/Response

► Registry Settings

• 270/271 Header/Footer Counter Segments
• 270/271 Unique Header/Footer IDs
• Add 'Services To Exclude From Verification'
• Add HL7 External Guarantor Code
• Allow 270 Submission For All Clients
• Charge Amount Determination Method
• Client Status
• Count Zero Charge Services Against Auths
• Create Single File Per Financial Class
• Create Single Functional Group (GS/GE) (270)
• Create Single Interchange Control (ISA/IEA)
• Create Single Transaction Set (ST/SE)(270)
• Display All Un-Billed Services
• Enable 270/271 Transaction Sets
• Enable 270/271 Submission on 834/820 Update
• Enable 270/271 Submission on Cross Episode Financial Eligibility
• Enable 270/271 Submission on Financial Eligibility
• Enable 270/271 Submission on Liability Update
• Enable 278 Authorization Request/Response Transaction
• Enable 3-Day Billing Rule
• Enable Coordination of Benefits (COB) Total Non-Covered Amount
• Enable Custom Claim Sort Logic
• Enable Group Ratio Roll-Ups
• Enable HIPAA Version 5010
• Enable ICD-10
• Enable Medigap Support
• Enable NCPDP Billing
• Enable PPS Billing
• Enable Real-Time 270/271 Submission
• Enable Same Day Service Exclusion
• Enable Service Liability Check (270)
• Enable Service Unit Splits
• Include Observe Medicare 24-Hour Rule
• Inhibit Liability - determinations
• Legal Status
• Missing Managed Care Authorization
• Non-Medicaid Certified Bed Stay
• Plan Coverage Description (2100C-EB-05)
• Require Authorizations At Guarantor/Payors Level
• Select Service/Appointment Inquiry Type
• Specify Posting Codes By Guarantor
• Specify Posting Codes by Guarantor Override
• Update Roll-Up Charges On Charge Entry/Delete
• Use 'Generate No-Pay ##0 Claims' Prompt To Determine Generation Of No-Pay Claims
• Use Unique App Transaction (BHT) IDs
• Use Unique Group (GS) Control IDs
• Use Unique Interchange (ISA) Control IDs
• Use Unique Transaction Set (ST) IDs

► See Also

• myAvatar CCBHC Forms and Functionality

► SQL Tables

• SYSTEM.billing_guar_table
• SYSTEM.billing_guar_table_834sub
• SYSTEM.billing_guar_table_tpreq