Avatar Cal-PM 2022 Update 19

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Product Requirements / Recommendations

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Product Update Form Description

The 'Pregnancy Indicator' section is added to the 'Guarantors/Payors' form to allow users to specify the postpartum period number of days by guarantor and optionally 'Aid Code' for services delivered to pregnant clients. This information is used in conjunction with the pregnancy start and end dates in the 'Women's Health History' form to populate the PAT-09 segment of the 2000B/2000C (Subscriber/Patient) loops in 837 Professional submissions. Additionally, separate 2000B/2000C (Subscriber/Patient) loops are now created for services occurring within the pregnancy date range (including postpartum period, if any) and services occurring outside of the pregnancy date range. Note this functionality is available only when the 'Enable Pregnancy Indicator / Date Of Last Menstrual Period' registry setting is enabled (has the value 'Y').

Included Updates

Required Updates

None

Details

NEW1 CHANGED0 FIXED0

New (1)

AV-74591 Details | User Acceptance Tests

Guarantors/Payors - Pregnancy Indicator

The 'Pregnancy Indicator' section is added to the 'Guarantors/Payors' form to allow users to specify the postpartum period number of days by guarantor and optionally 'Aid Code' for services delivered to pregnant clients.

This information is used in conjunction with the pregnancy start and end dates in the 'Women's Health History' form to populate the 2000B/2000C (Subscriber/Patient) loop in 837 Professional submissions. Additionally, separate 2000B/2000C (Subscriber/Patient) loops are now created for client services that occur within the pregnancy date range (including postpartum period, if any) and services that are outside of the pregnancy date range. Note this functionality is available only when the 'Enable Pregnancy Indicator / Date Of Last Menstrual Period' registry setting is enabled.

The 837 process has been updated to allow for the creation of multiple 2000B loops within a single claim file / billing period – one 2000B and claim loop for dates of service that fall outside of the client’s pregnancy record and another for dates of services that fall within the client’s pregnancy record.

Value Added: Increases flexibility when billing services for pregnant/postpartum patients.

Topics

• 837 Professional

Acceptance Tests

AV-74591 Summary | Details

Guarantors/Payors - Pregnancy Indicator

Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:

Admission (Outpatient)
App Dashboard
California MEDS File Load
Client Charge Input
Diagnosis
Dictionary Update (PM)
Dynamic Form - Admission - Client
Electronic Billing
Financial Eligibility
Guarantors/Payors
Practitioner Numbers By Guarantor and Program
Program Maintenance
Registry Settings (PM)
Service Codes
User Definition
Women's Health History

Scenario 1: 837 Professional - Enable Pregnancy Indicator / Date Of Last Menstrual Period = Y

Specific Setup:

Registry Settings:
The 'Enable Pregnancy Indicator / Date Of Last Menstrual Period' has a value of 'Y'.
Dictionary Update:
Client Dictionary # 357- Pregnancy Status contains values, including the extended dictionary values.
California MEDS File:
A file is available to load.
The file contains a pregnant client. Note the episode, guarantor, share of cost, and aid code.
Guarantors/Payors:
A minimum of the above guarantor has values in the required 'Postpartum Period (Number of Days)' field and the optional 'Aid Code' field of the ' Pregnancy Indicator' section of the form. Note the values.
Client from the California MEDS File:
Note the episode program.
Is assigned the noted guarantor in Financial Eligibility.
Has a diagnosis record for the dates of service.
The share of cost has been met.
Has a 'Women's Health History' record with a date in 'Pregnancy Start Date' and optionally a date in 'Pregnancy End Date'.
If 'Pregnancy End Date' contains a value, services would qualify for billing through the date, plus the number of days in the 'Postpartum Period (Number of Days)' field, but only if the 'Aid Code' field matches the 'Aid Code' in the California MEDS File.
Services:
Services exist and can be before the date of pregnancy, during the date of pregnancy, after the date of pregnancy, and after the date of pregnancy plus the number of days in the 'Postpartum Period (Number of Days)'.
Guarantor/Program Billing Defaults:
837 Professional section of desired template:
Maximum Service Information Per Claim Information (Maximum LX Per CLM) does not equal '1'.
Create Interim Billing Batch File:
Create a batch for the guarantor, program, dates of service and client.
Close Charge has been used to close the charges.

Steps

Open 'Electronic Billing'.
Create an 837 Professional bill for the interim batch and dates of service for the client from Setup.
Review the 'Dump' file.
Validate that the services within the date range that the client is not pregnant or has passed the number of days in the ' 'Postpartum Period (Number of Days)', contain the following in the 'PAT' segment: 'PAT*G8~'.
Validate that the services within the date range that the client is pregnant or has not passed the number of days in the ' 'Postpartum Period (Number of Days)', contain the following in the 'PAT' segment: 'PAT*G8********Y~'.
Close the dump file.
Close the form.

Scenario 2: 837 Professional - Enable Pregnancy Indicator / Date Of Last Menstrual Period = N

Specific Setup:

Registry Settings:
The 'Enable Pregnancy Indicator / Date Of Last Menstrual Period' has a value of 'N'.
Dictionary Update:
Client Dictionary # 357- Pregnancy Status contains values, including the extended dictionary values.
California MEDS File:
A file is available to load.
The file contains a pregnant client. Note the episode, guarantor, share of cost, and aid code.
Guarantors/Payors:
A minimum of the above guarantor has values in the required 'Postpartum Period (Number of Days)' field and the optional 'Aid Code' field of the ' Pregnancy Indicator' section of the form. Note the values.
Client from the California MEDS File:
Note the episode program.
Is assigned the noted guarantor in Financial Eligibility.
Has a diagnosis record for the dates of service.
The share of cost has been met.
Has a 'Women's Health History' record with a date in 'Pregnancy Start Date' and optionally a date in 'Pregnancy End Date'.
If 'Pregnancy End Date' contains a value, services would qualify for billing through the date, plus the number of days in the 'Postpartum Period (Number of Days)' field, but only if the 'Aid Code' field matches the 'Aid Code' in the California MEDS File.
Services:
Services exist and can be before the date of pregnancy, during the date of pregnancy, after the date of pregnancy, and after the date of pregnancy plus the number of days in the 'Postpartum Period (Number of Days)'.
Guarantor/Program Billing Defaults:
837 Professional section of desired template:
Maximum Service Information Per Claim Information (Maximum LX Per CLM) does not equal '1'.
Create Interim Billing Batch File:
Create a batch for the guarantor, program, dates of service and client.
Close Charge:
Close the charges for the Interim Batch or the client.

Steps

Open 'Electronic Billing'.
Create an 837 Professional bill for the interim batch and dates of service for the client from Setup.
Review the 'Dump' file.
Validate that all 'PAT' segment:s contain 'PAT*G8~'.
Close the dump file.
Close the form.

Topics

• 837 Professional