This article is part of the systems administration guide. You will require administration access to view the pages mentioned in this article.
Add a Guarantor
1. Click Administration.
2. Select Accounting from menu.
2. Select Guarantor from menu.
3. Click New under the banner.
4. Complete the below fields.
5. Select Create Guarantor button at the bottom of the page.
Notice
When configuring Health Fund Guarantors it is important to understand how the various health fund codes are configured for health fund claiming and statutory reporting purposes.
Admin > Accounting > Guarantors
When editing a Guarantor there is a field in the "Statutory Reporting" section called "Code". This value needs to contain the code that is required to be submitted to state and federal statutory reporting authorities in relation to admitted patient data. Examples of these are HCP, PHDB, PHISCO, VAED etc.
If the guarantor is part of a fund group then the admission records related to that guarantor will be included with the fund group and use the fund groups code. If this guarantor is a member of a fund group, but is required to report individually on HCP/PHDB reports then select the checkbox "Report separate to fund group on HCP report". If this is checked then this guarantor will be reported separately and use the code entered for this guarantor.
The code that is submitted for claiming purposes is set by linking the guarantor to a Medicare Participant record in the Medicare Participants administrative screen. If no link is setup then the "Statutory Reporting" > "Code" value will be used as a fall back.
Admin > Medicare Participants
| Field | Description | Example |
| Details | ||
| Code | This code is used as a CareRight identifier to interface with other systems within the organisation (ie Hospital system - HL7). This field is not used for Eclipse transmission rather used for matching/linking between CR and other systems. | |
| Name | Name of the health fund (a maximum of 50 characters is allowed, including provider code, account type and guarantor name) | ACA Health Benefits Fund |
| Type | This is a drop down list | Health Insurance Fund |
| A field for Guarantor's email address | example@exampletest.com | |
| Address | This is the street address for the guarantor | LOCKED BAG 2014 |
| Suburb | This is the Suburb for the guarantor | WAHROONGA |
| State | This is a drop down list with the states | NSW |
| Postcode | ||
| Phone | A maximum of 100 characters is allowed. | |
| Fax | ||
| Disabled Status(Check box) | Check this value to make the Guarantor inactive | False/no |
| Theatre | ||
| Theatre Band List | Select from drop down list - as per your site configuration. See Theatre Banding Overview for configuration. | |
| Procedure 1 Percentage | The percentage of charge amount for procedure 1. This models the Multiple Operation Rule (sometimes known as the Multiple Procedure Rule, or Multiple Theatre Rule). For private rates, this is set via a Assign Rate Table to Patient Account | 100% |
| Procedure 2 Percentage | The percentage of charge amount for procedure2 | 80% |
| Procedure 3 Percentage | The percentage of charge amount for procedure3 | 60% |
| Subsequent Procedure Percentage | The percentage of charge amount for the subsequent procedure | 40% |
| Claiming | ||
| Rate | Inpatient Rate. This is a drop down list- This list relates to the values populated in Accounting/Rate Definitions. This is typically a model of the health fund's contract with the hospital. Where a guarantor is a member of a group of funds, be sure to choose the rate that matches that group. | AHSA |
| Outpatient Rate | Outpatient Rate can be mapped into different rate table if required. | |
| Minimum Benefit Rate | Where Minimum Benefits may apply due to health fund policy restrictions (example: IVF), a rate definition can be nominated to model the legislated rates. This rate is selected when a patient account has the Minimum Benefit flag selected. | |
| Calming Method | Select from drop down list | Online |
| Day Hospital IHC Claiming | This is a drop down list. This needs to be set correctly for in Hospital Claiming for Day Hospitals | The options are: No claiming, Electronic (Thelma), Electronic (Eclipse), Paper Claiming |
| Other IHC Claiming (non Day Hospital) | Select from drop down list | The options are: No Claiming, Electronic (Thelma), Paper Claiming |
| Default Grouper Version | This allows the individual Grouper to be set per Guarantor. This is a drop down list. If not set the default Grouper version will be applied. | blank |
| All Services are Taxable supplies (Check box) | Check this value | False/No |
| Default Fund Payee ID (IMC) | Used for IMC | |
| Default Hospital Claim Type | These values are applied to invoice created to this guarantor when the invoice is for inpatient medical claims (IMC). This should be set to the value as stipulated by the health fund. In our experience all health funds use "Agreements" excepts for Medibank Private that use "Scheme" | The options are: Billing Agent Medicare Only, Private hospital claim, public hospital claim, Agreements, Scheme, Billing Agent, Patient Claims |
| Default Hospital Consent | These values are applied to invoice created to this guarantor when the invoice is for inpatient medical claims(IMC). This should be set to the value as stipulated by the health fund. In our experience all health funds use "Verbal" except for Medibank Private that use "Not obtained" | |
| Medicare Participants | Select the Medicare participants the fund use. See Medicare Participants list in Administration. | |
| Health Fund Details | ||
| Grouping | Drop down select. Select if Health Fund is individual fund. Group of Funds and Member of Group funds | Member of Group Funds |
| Member of Group of Funds | This field will only appear if "Member of a group of Funds" is selected above | Australian Health Service Alliance |
| Gap Type | This is a drop down list 1. If the gap type is known gap, this means Careright will use the private rates as the item price and fund price will be the heath fund rate 2. If there was a rate contract created, the gap type must be no gap, so that you can choose from your rate contract list | |
| Maximum Procedure Gap | 0.0 | |
| Use Parent Fund For Claiming (check box) | Where a Guarantor is a member of a group of funds, and your agreements with the health funds are applicable to the entire group, you can simply opt in to using a single set of claim contracts at the group of funds levels. | Eg: if you had an agreement with the AHSA group, for each fund under their umbrella you can now select Use parent fund for claiming. |
| Statutory Reporting | ||
| Code | This is the registered code for the guarantor as recognised by Medicare | ACA |
| HCP payer Identifier | This is a drop down list - This must be populated for statutory reporting | Insured with agreement with hospital |
| HMDS Funding Source | This is a drop down list - This must be populated for statutory reporting | Australian Funding source |
| QHAPDC Funding Source | This is a drop down list - This must be populated for statutory reporting | Private Health Insurance |
| AAPC Funding Source | This is a drop down list - This must be populated for statutory reporting | Other Hospital or public authority |
| ISAAC Funding source | This is a drop down list - This must be populated for statutory reporting | |
| TSMS Funding Source | This is a drop down list - This must be populated for statutory reporting | |
| Report separate to fund group on HCP report | ||
| Clients eligible for Medicare for statutory reporting purposes | Used to ensure Medicare eligibility, particularly for QHAPDC reporting | |
