Claims Processing Overview

The claims process reconciles claims for provider services.

The batch is a group of claims that allows many claims to be reconciled at one time:
The batch is created (Batch Creation form).
Claims are added to the batch
The batch is closed.

The EOB is an explanation of how claims were reconciled:
The voucher is created
The EOB is created

Provider Service Claims are processed for payment in four steps:

Batch creation
Contains a set of claims
Claim processing entry, and adjudication
Batch closure, the service is pushed to myAvatar PM, Cal-PM
Create voucher, and create EOB
Vouchers are an intermediate step between creating a batch, and creating an EOB.
The voucher divides a large batch into smaller sub-batches for a maximum dollar amount.
The EOB Creation form defines the maximum reimbursement for the EOB, and the maximum total reimbursement when creating an EOB.

Add claims through the Claims Processing (CMS 1500) form for CPT Service Codes, or Claims Processing (UB-04) form for Revenue Codes.
Close the batch (Close Batch form).
Ensure that all claims that should be included are contained in the batch. Once a batch is closed it cannot be opened again.
Create vouchers (Create Voucher form). Vouchers are only available after batches are closed.
Create the EOB (Create EOB form). EOBs are only available once a voucher has been created.

If claims are adjudicated automatically, a second cycle of adjudication is performed when the batch is closed.
The claims are adjudicated based upon the setup of the second adjudication.
Manually overridden services are skipped.

Avatar MSO Claims Processing Adjudication Rules documentation can be downloaded here.