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Step 1 - Member information

Updated on August 31, 2021

This step lets you enter patient and subscriber information, as well as other insurance payment information, if required.

SCE provides the option for you to search for and select a member during manual claim entry. Open the search by clicking Search members at the bottom right of the member information slot. A modal with search fields opens. Selecting a member returned in the search and clicking Choose member auto populates the Patient ID field and other demographic fields on the screen, assuming the data is available in the member system.

Senior claims examiners also have the option to manually choose a policy – but this policy will be used only to populate the patient ID in the patient section in order to proceed further with claim entry. The actual policy selection for the claim occurs in the policy selection and eligibility module.

The fields in the member information step are listed below and are displayed when entering professional, institutional, and dental claims. The * indicates a required field.

Step/SectionFieldDefinition
Member informationPatient IDThe patient’s identification number. If the ID is matched to an existing member record, other demographic fields on the screen will auto populate, assuming the data is available in the member system.
Member informationPolicy role/relationship*The patient’s relationship to the subscriber. Select from the drop-down list.
Member information – PERSONAL INFOFirst nameFirst name of the patient
Member information – PERSONAL INFOMiddle Middle name or initial of the patient
Member information – PERSONAL INFOLast name*Last name of the patient
Member information – PERSONAL INFOGender*Gender of the patient. Select from the dropdown list.
Member information – PERSONAL INFODate of birth*Date of birth of the patient. Use the date picker or enter as MM/DD/YYYY
Member information – PERSONAL INFOAddress 1*The first line of the patient’s address
Member information – PERSONAL INFOAddress 2The second line of the patient’s address
Member information – PERSONAL INFOCity*The patient’s city
Member information – PERSONAL INFOStateThe patient’s state. Choose from the dropdown list.
Member information – PERSONAL INFOZipThe patient’s zip code
Member information – PERSONAL INFOPhone The phone number of the patient
Member information – PERSONAL INFOEmailThe email address of the patient
Member information – POLICYSubscriberThe policy subscriber’s first and last name followed by their ID
Member information – POLICYPayer Responsibility sequence number code*Indicates the policy’s order of responsibility for adjudicating the claim. Choose from the dropdown list.
Member information – POLICYPlan nameThe plan name

If subscriber data changes are required, select the gear icon next to the policy number to open a modal and update subscriber demographic information. The fields available in the modal are listed below and are displayed when entering professional, institutional, and dental claims.

Step/SectionFieldDefinition
Update subscriber detailsSubscriber ID*The ID of the subscriber
Update subscriber detailsPolicy role/relationshipThe relationship code of the subscriber. Note that this is set to 00 – Subscriber and cannot be updated.
Update subscriber detailsPayer nameThe payer name for the policy
Update subscriber details – PERSONAL INFOFull name*The first, middle, and last name of the subscriber
Update subscriber details – PERSONAL INFOGenderThe subscriber’s gender. Select from the dropdown list.
Update subscriber details – PERSONAL INFODate of birthDate of birth of the subscriber. Use the date picker or enter as MM/DD/YYYY
Update subscriber details – PERSONAL INFOAddress line 1The first line of the subscriber’s address
Update subscriber details – PERSONAL INFOAddress line 2The second line of the subscriber’s address
Update subscriber details – PERSONAL INFOCity*The subscriber’s city
Update subscriber details – PERSONAL INFOStateThe subscriber’s state. Choose from the dropdown list.
Update subscriber details – PERSONAL INFOZipThe subscriber’s zip code
Update subscriber details – PERSONAL INFOPhoneThe phone number of the subscriber
Update subscriber details – PERSONAL INFOEmailThe email address of the subscriber

The lower right side of the Member information slot displays the Patient has other policies (COB) checkbox. Selecting the check box allows you to + Add other policies for coordination of benefits purposes. The fields in the Add other policy subscriber modal are listed below and are displayed when entering professional, institutional, and dental claims.

Step/SectionFieldDefinition
Add other policy subscriber – OTHER SUBSCRIBEROther subscriber ID*The other policy subscriber’s ID number
Add other policy subscriber – OTHER SUBSCRIBERIndividual relationship code*The relationship code of the patient to the other subscriber
Add other policy subscriber – OTHER SUBSCRIBERPayer Responsibility sequence number*Indicates the policy’s order of responsibility for adjudicating the claim. Choose from the dropdown list.
Add other policy subscriber – OTHER SUBSCRIBERLast nameThe last name of the other subscriber
Add other policy subscriber – OTHER SUBSCRIBERBenefit assignment indicator*Choose from Yes, No, or Not applicable
Add other policy subscriber – OTHER SUBSCRIBERFirst nameThe first name of the other subscriber
Add other policy subscriber – OTHER SUBSCRIBERRelease of information*Choose I or Y
Add other policy subscriber – OTHER PAYEROther payer ID*The plan ID of the other payer
Add other policy subscriber – OTHER PAYERPayer name*Name of other payer
Add other policy subscriber – OTHER PAYERClaim control numberOther payer claim number
Add other policy subscriber – OTHER PAYER PAYMENTPaid amountAmount paid by the other payer
Add other policy subscriber – OTHER PAYER PAYMENTCheck numberThe check number of the other payer’s claim payment
Add other policy subscriber – OTHER PAYER PAYMENTPatient’s remaining liabilityPatient liability from the other payer
Add other policy subscriber – OTHER PAYER PAYMENTPaid dateThe paid date of the other payer’s claim payment
Add other policy subscriber – OTHER PAYER PAYMENTNon covered amountAmount not covered by the other payer

The lower right side of the Add other policy subscriber provides an area to enter claim level adjustments. Clicking + Add adjustment group code provides access to enter information in the fields listed below and are displayed when entering professional, institutional, and dental claims.

Step/SectionFieldDefinition
Add other policy subscriber – CLAIM LEVEL ADJUSTMENTSAdjustment group code*The claim adjustment group code; choose from the dropdown list.
Add other policy subscriber – CLAIM LEVEL ADJUSTMENTSReason code*The claim adjustment reason code; choose from the dropdown list.
Add other policy subscriber – CLAIM LEVEL ADJUSTMENTSAmount*Amount adjusted by the other payer
Add other policy subscriber – CLAIM LEVEL ADJUSTMENTSQuantityThe service units adjusted by the other payer

Notes:

  • You may enter multiple Reason codes, Amounts, and Quantities under a single Adjustment group code by clicking +Add reason code
  • You may enter multiple adjustment group codes (and associated information) by clicking +Add adjustment group code

Once you have entered the member information, click Next on the bottom right of the screen to advance to the next step.

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