Avatar Cal-PM 2022 Update 77

1. Open 'Registry Settings' form.
2. Enter search value 'Require Authorizations At Guarantors/Payors Level' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Require Authorizations At Guarantors/Payors Level' is returned (under 'Avatar PM -> System Maintenance -> Guarantors/Payors' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting 'Y' allows filing for the 'Authorization Group Definition' form, adds the 'Authorization Group', 'Program', and 'Practitioner Category' fields to the 'Payor Based Authorizations' form, modifies the 'Expiration Date' field in the 'Payor Based Authorizations' form to be not required, modifies the 'Service Code', 'Program', and 'Guarantor' fields in the 'Payor Based Authorizations' form to be multiple select, adds the 'Authorization Group(s)' fields to the 'Guarantors/Payors' (Authorization Information) form, new fields will be added to the 'Guarantors/Payors' (Authorization Information) form which will enable the user to identify if an authorization should be required. In the 'Managed Care Authorizations' (Managed Care Authorization Data) form the 'Authorization Number' field will no longer be required. Selecting 'Y' also modifies the 'Authorization Group' field in the 'Managed Care Authorizations' (Managed Care Authorization Data) form so that if a selection is made in the 'Authorization Group' field the 'Service Code' field will be limited to the Service Codes in the selected Authorization Group.

Selecting 'N' disallows filing for the 'Authorization Group Definition' form, removes the 'Authorization Group', 'Program', and 'Practitioner Category' field from the 'Payor Based Authorizations' form, the 'Expiration Date' field in the 'Payor Based Authorizations' form will be required, the 'Service Code', 'Program', and 'Guarantor' field in the 'Payor Based Authorizations' form will be single select, removes the 'Authorization Group(s)' fields from the 'Guarantors/Payors' (Authorization Information) form, new fields in the 'Guarantors/Payors' (Authorization Information) form which will enable the user to identify if an authorization should be required will be removed. In the 'Managed Care Authorizations' (Managed Care Authorization Data) form the 'Authorization Number' field will be required. Selecting 'N' also changes the 'Authorization Group' logic back in the authorization forms."

• Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar Cal-PM 'Guarantors/Payors' form.
2. Select Add or Edit action in 'Add New or Edit Existing Guarantor' field.
3. Enter new (or select existing) Guarantor Code.
4. Complete all required/desired fields in main section of 'Guarantors/Payors' form.
5. Navigate to 'Authorization Information' section of 'Guarantors/Payors' form.
6. Ensure the following fields/buttons are present in form:
7. 'Verify Services and Appointments Against Available Authorizations'
8. Selection values for 'Check For Available Dollars', 'Check For Available Units' and/or 'Check For Available Visits'
9. 'Verification Level For Authorizations For Client Charge Input'
10. 'Verification Level For Authorizations For Appointment Scheduling'
11. 'Verification Level For Authorizations For 837 Electronic Billing'
12. 'Preauthorization Notice Upon Assignment'
13. 'Authorization Groups'
14. Ensure that sub-section for input of Authorization Requirements by date/service code is present where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled, including the following fields:
15. 'Effective Date'
16. 'Expiration Date'
17. 'Authorization Group'
18. 'Service Code(s)'
19. Multiple selection field for Authorization Requirement date/service code row, including 'All Service Codes' selection; required
20. 'Require Authorization'
21. Yes/No radio button selection field, required
22. Determines whether applicable Authorization (Managed Care Authorization or Payor Based Authorization) is required for selected dates/service code allowance in Client Charge Input, Appointment Scheduling and/or 837 Electronic Billing
23. 'Require Authorization Number'
24. Yes/No radio button selection field, required
25. Determines whether Authorization Number in applicable Managed Care Authorization or Payor Based Authorization is required for selected dates/service code allowance in Client Charge Input, Appointment Scheduling and/or 837 Electronic Billing
26. 'Select Authorization Item'
27. Selection field for Authorization Requirement date/service code rows
28. 'Update' button
29. 'Delete' button
30. Enter 'Effective Date' and 'Expiration Date' (if desired) for Service Authorization Requirement date/service code row entry.
31. Select one or more codes or 'All Service Codes' in 'Service Code(s)' multiple selection field, or select grouping in 'Authorization Group' field and ensure that codes in group are selected in 'Service Codes' field.
32. Select value for 'Require Authorization Number' and 'Select Authorization Item' fields.
33. Click 'Update' button to save Authorization Requirement date/service code row entry.
34. Ensure that Authorization Requirement date/service code row entry is displayed as entered/updated in the 'Authorization Group Information' display field.
35. Repeat steps 8-11 above for additional Authorization Requirement date/service code row entries as desired.
36. For Authorization Requirement date/service code row edit, select desired entry in the 'Select Authorization Item' field; make desired changes and click 'Update' button to save Authorization Requirement date/service code row update.
37. For Authorization Requirement date/service code row deletion, select desired entry in the 'Select Authorization Item' field and click 'Delete' button.
38. Navigate to main/first section of 'Guarantors/Payors' form.
39. Click 'File' button to file Guarantor/Payor information, including Authorization Information/Authorization Requirement entries.
40. Select 'Edit' option, and select Guarantor entered/defined above.
41. Navigate to 'Authorization Information' section of 'Guarantors/Payors' form.
42. Ensure all field values are present in Authorization Information section of 'Guarantors/Payors' form as previously entered/filed, including all Authorization Requirement date/service code entry row(s).
43. Open Crystal Reports or other SQL reporting tool.
44. In Avatar Cal-PM SQL table 'SYSTEM.billing_guar_table', ensure that entered/filed Guarantor information is present.
45. In Avatar Cal-PM SQL table 'SYSTEM.billing_guar_auth_table', ensure that entered/filed Guarantor Authorization Requirement date/service code information is present.

• Avatar Cal-PM Registry Setting 'Require Authorizations at Guarantors/Payors Level' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar Cal-PM 'Authorization Group Definition' form (under 'Avatar PM -> System Maintenance -> System Definition' menu).
2. Ensure the following fields/buttons are present in form:
3. 'Add, Edit Or Delete'
4. Radio button selection field
5. 'Authorization Group'
6. Selection field for 'Edit' and/or 'Delete' options
7. 'File Authorization Group' button
8. 'Authorization Group Name'
9. 'Status'
10. Radio button selection field, 'Active'/'Inactive', default value 'Active'
11. 'Authorization Group Information'
12. Multiple row display field for all Authorization Group date/service code rows entered
13. 'Select Row To Edit'
14. Selection field for Authorization Group date/service code rows
15. 'Update' button
16. 'Delete' button
17. 'Effective Date'
18. Effective date for Authorization Group date/service code row; required
19. 'Expiration Date'
20. Expiration date for Authorization Group date/service code row
21. 'Service Code(s)'
22. Multiple selection field for Authorization date/service code row, including 'All Service Codes' selection; required
23. Select 'Add' option, and enter value for 'Authorization Group Name' field.
24. Enter 'Effective Date' and 'Expiration Date' (if desired) for Authorization Group date/service code row entry.
25. Select one or more 'Service Code(s)' value for Authorization Group date/service code row entry (or optionally select 'All Service Codes').
26. Click 'Update' button to save Authorization Group date/service code row entry.
27. Ensure that Authorization Group date/service code row entry is displayed as entered/updated in the 'Authorization Group Information' display field.
28. Repeat steps 4-6 above for additional Authorization Group date/service code row entries as desired.
29. For Authorization Group date/service code row edit, select desired entry in the 'Select Row To Edit' field; make desired changes and click 'Update' button to save Authorization Group date/service code row update.
30. For Authorization Group date/service code row deletion, select desired entry in the 'Select Row To Edit' field and click 'Delete' button.
31. Click 'File Authorization Group' button to file/save Authorization Group (along with Authorization Group date/service code row entries as defined).
32. Ensure user is presented with confirmation dialog noting 'Filed Successfully'; click 'OK' button to return to form.
33. Select 'Edit' option, and select Authorization Group entered/defined above.
34. Ensure all field values are present in 'Authorization Group Definition' form/record as previously entered/filed, including all Authorization Group date/service code entry row(s).
35. Open Crystal Reports or other SQL reporting tool.
36. In Avatar Cal-PM SQL table 'SYSTEM.table_auth_group', ensure that entered/filed Authorization Groups are present.
37. In Avatar Cal-PM SQL table 'SYSTEM.table_auth_group_svc_cds', ensure that entered/filed Authorization Group date/service code row entries are present.

• Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' may optionally be enabled/disabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar Cal-PM 'Managed Care Authorizations' form.
2. Select client/episode for Managed Care Authorization entry/update/view.
3. Navigate to 'Managed Care Authorization Data' section of form.
4. Click 'Add New Item' button for Managed Care Authorization entry (or select existing Authorization/row and click 'Edit Selected Item' button).
5. Ensure the following fields are present in the 'Payor Based Authorizations' form:
6. 'Guarantor Number' / 'Guarantor Name'
7. 'Authorization Start Date'
8. 'Authorization End Date'
9. 'Service Code'
10. Multiple selection field (including 'All Service Codes' selection)
11. 'Authorization Group'
12. Available only where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled
13. Authorization Number'
14. Not a required field where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled
15. 'Maximum Dollar Amount' / 'Maximum Units' / 'Maximum Visits'
16. 'Practitioner Categories Necessary For Coverage'
17. 'Type Of Authorization'
18. 'U/R Staff Person'
19. Select value in 'Guarantor Number' / 'Guarantor Name' field.
20. Enter/select values in 'Authorization Start Date' and 'Authorization End Date' fields.
21. Select one or more codes or 'All Service Codes' in 'Service Code' multiple selection field, or select grouping in 'Authorization Group' field and ensure that codes in group are selected in 'Service Codes' field (and limited to only codes specified for group).
22. Enter value in 'Authorization Number' field if required/desired.
23. Enter/select values for all other Managed Care Authorization fields as required/desired.
24. Repeat steps 4-10 above for additional Managed Care Authorization record/row entries as desired.
25. Click 'Submit' button to file 'Managed Care Authorizations' form/record(s).
26. Re-open Avatar Cal-PM 'Managed Care Authorizations' form for same client/episode where Authorization information filed above.
27. Navigate to 'Managed Care Authorization Data' section of form.
28. Select existing Authorization/row and click 'Edit Selected Item' button
29. Ensure all field values are present in 'Managed Care Authorizations' form/record as previously entered/filed.
30. Open Crystal Reports or other SQL reporting tool.
31. In Avatar Cal-PM SQL table 'SYSTEM.history_managed_care_auths', ensure that data row(s) are added/updated on filing of 'Managed Care Authorizations' form and contain values/information filed via form for all applicable fields (including 'Authorization Group' value where entered).

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' may optionally be enabled/disabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' may optionally be enabled/disabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar Cal-PM 'Payor Based Authorizations' form (under 'Avatar PM / System Maintenance / System Definition' menu).
2. Select 'Add' action in 'Add/Edit/Delete' field (or select 'Edit' action and click 'Select Authorizations To Edit/Delete' button to view/update existing Payor Based Authorization record/entry).
3. Ensure the following fields are present in the 'Payor Based Authorizations' form:
4. 'Guarantor'
5. 'Program'
6. Available only where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled
7. 'Practitioner Category'
8. Available only where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled
9. 'Effective Date'
10. 'Expiration Date'
11. Not a required field where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled
12. 'Authorization Number'
13. 'Service Code' / 'Service Code(s)'
14. Not available where Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled
15. 'Service Code' is a single code search/select field where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is disabled
16. 'Service Code(s)' is a multiple selection field (including 'All Service Codes' selection) where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled
17. 'Authorization Group'
18. Available only where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled
19. 'Select CPT ® Codes' button
20. Available only where Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled
21. 'All CPT Codes'
22. Available only where Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled
23. 'Display Authorizations' button
24. 'Select Authorizations To Edit/Delete' button
25. Enter/select values in 'Effective Date' and 'Expiration Date' fields.
26. Where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled - select one or more values in 'Program' and/or 'Practitioner Category' multiple selection fields if desired.
27. Where Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' is enabled - select one or more codes or 'All Service Codes' in 'Service Code(s)' multiple selection field, or select grouping in 'Authorization Group' field and ensure that codes in group are selected in 'Service Codes' field (and limited to only codes specified for group).
28. Where Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled - Click 'Select CPT Codes' button and enter one or more code selections in the multi-iteration grid displayed (or set 'All CPT Codes' field to 'Yes').
29. Enter 'Authorization Number' field value.
30. Click 'Submit' button to file 'Payor Based Authorizations' form/record.
31. Select 'Edit' action in 'Add/Edit/Delete' field and click 'Select Authorizations To Edit/Delete' button to view/update previously entered Payor Based Authorization record/entry.
32. Ensure all field values are present in 'Payor Based Authorizations' form/record as previously entered/filed.
33. Click 'Display Authorizations' button to display the Payor Based Authorizations report/information.
34. In Payor Based Authorizations report display/results, ensure that all Payor Based Authorization entries/records for selected 'Guarantor' value are displayed, including the following fields:
35. 'Guarantor'
36. 'Service Code' or 'CPT Code'
37. Dependent on Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations'
38. 'Program'
39. 'Practitioner Category'
40. 'Effective Date'
41. Expiration Date'
42. 'Authorization Number'
43. Open Crystal Reports or other SQL reporting tool.
44. Where Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is disabled - In Avatar Cal-PM SQL table 'SYSTEM.table_payor_auths', ensure that data row(s) are added/updated on filing of 'Payor Based Authorizations' form and contain values/information filed via form for all applicable fields (including 'Program' and 'Practitioner Category' values where entered).
45. Where Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled - In Avatar Cal-PM SQL table 'SYSTEM.table_payor_auths_cpt', ensure that data row(s) are added/updated on filing of 'Payor Based Authorizations' form and contain values/information filed via form for all applicable fields (including 'Program' and 'Practitioner Category' values where entered).

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' may optionally be enabled/disabled
• One or more Guarantor(s) where values are selected/defined for 'Verify Services and Appointments Against Available Authorizations' and 'Verification Level For Authorizations For Client Charge Input' fields (via Avatar Cal-PM 'Guarantors/Payors' form, 'Authorization Information' section)
• Client record eligible for 'Client Charge Input' form service entry where applicable Guarantor(s) is/are assigned via client Financial Eligibility record for service liability distribution

1. Open Avatar Cal-PM 'Client Charge Input' form.
2. Note, acceptance testing may also be confirmed via Avatar Cal-PM 'Client Charge Input (Charge Fee Access)', 'Client Charge Input With Diagnosis Entry', 'Client Charge Input (Charge Fee Access And Diagnosis Entry)', 'Recurring Client Charge Input', 'Recurring Client Charge Input (Charge Fee Access)', 'Recurring Client Charge Input With Diagnosis Entry' and/or 'Recurring Client Charge Input (Charge Fee Access And Diagnosis Entry)' forms
3. Enter value for 'Date of Service'.
4. Enter/select values for 'Client ID', 'Episode Number', 'Program', 'Service Code' and 'Practitioner' fields (and any other fields as desired/required).
5. For service codes/dates of service not included/designated in Authorization requirements for applicable/liable Guarantor (via 'Guarantor/Payors' form, 'Authorization Information' section):
6. In case where no Managed Care Authorization record exists for selected client applicable to service criteria/entry values and no Payor Based Authorization record exists in system applicable to service criteria/entry values - Ensure that user is not presented with Error/Warning message and Service entry is allowed without requirement for coverage by Managed Care Authorization/Payor Based Authorization record(s).
7. For service codes/dates of service designated to require Authorization for applicable/liable Guarantor but where 'Require Authorization' field is set to 'No' (via 'Guarantor/Payors' form, 'Authorization Information' section):
8. In case where no Managed Care Authorization record exists for selected client applicable to service criteria/entry values and no Payor Based Authorization record exists in system applicable to service criteria/entry values - Ensure that user is not presented with Error/Warning message and Service entry is allowed without requirement for coverage by Managed Care Authorization/Payor Based Authorization record(s).
9. For service codes/dates of service designated to require Authorization for applicable/liable Guarantor and where 'Require Authorization' field is set to 'Yes' (via 'Guarantor/Payors' form, 'Authorization Information' section):
10. In case where no Managed Care Authorization record exists for selected client applicable to service criteria/entry values and no Payor Based Authorization record exists in system applicable to service criteria/entry values - Ensure that user is presented with Error/Warning message noting 'No valid authorizations found on file.'
11. In case where Managed Care Authorization record exists for selected client applicable to service criteria/entry values but is exhausted/cannot be used for additional services (due to Available Dollars/Available Units/Available Visits limitations), and no Payor Based Authorization record exists in system applicable to service criteria/entry values - Ensure that user is presented with Error/Warning message noting 'Authorization On File For Guarantor Will Be Exhausted With Requested Services.'
12. In case where Managed Care Authorization record exists for selected client applicable to service criteria/entry values and is not exhausted/can be used for additional services - Ensure that user is not presented with Error/Warning message and Service entry is allowed due to coverage by Managed Care Authorization record(s).
13. In case where no Managed Care Authorization record exists for selected client applicable to service criteria/entry values (or Managed Care Authorization record exists but is exhausted/cannot be used for additional services) but Payor Based Authorization record exists in system applicable to service criteria/entry values - Ensure that user is not presented with Error/Warning message and Service entry is allowed due to coverage by Payor Based Authorization record(s).
14. Notes for service code/date of service Authorization requirements outlined above:
15. If 'Require Authorization Number' field is set to 'Yes' for service code/date Authorization requirement (via 'Guarantor/Payors' form, 'Authorization Information' section), 'Authorization Number' value must also be filed/present for applicable Managed Care Authorization/Payor Based Authorization record for service entry to be allowed without error.
16. For Managed Care Authorizations - Records/Authorizations applicable to 'Date Of Service' entry/value will be those where 'Date of Service' is on or after 'Authorization Start Date' and on or before 'Authorization End Date' (including records where 'Date of Service' is same as 'Authorization End Date').
17. For Payor Based Authorizations - Records/Authorizations applicable to 'Date Of Service' entry/value will be those where 'Date of Service' is on or after 'Effective Date' and before 'Expiration Date' (not including records where 'Date of Service' is same as 'Expiration Date'). If 'Expiration Date' is not defined, Payor Based Authorization will be considered applicable to all dates of service on/after 'Effective Date'.
18. Service entry via 'Client Charge Input' forms may be disallowed or allowed following error/warning message, dependent on 'Verification Level For Authorizations For Client Charge Input' configuration for applicable Guarantor (via Avatar Cal-PM 'Guarantors/Payors' form, 'Authorization Information' section).

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' may optionally be enabled/disabled
• One or more Guarantor(s) where values are selected/defined for 'Verify Services and Appointments Against Available Authorizations' and 'Verification Level For Authorizations For 837 Electronic Billing' fields (via Avatar Cal-PM 'Guarantors/Payors' form, 'Authorization Information' section)
• One or more service(s) eligible for Avatar Cal-PM 837 Professional or 837 Institutional file inclusion under applicable Guarantor(s) (via 'Electronic Billing' form)

1. Open Avatar Cal-PM 'Electronic Billing' form.
2. Note, acceptance testing may also be confirmed via Avatar Cal-PM 'Quick Billing' form/functionality.
3. Select '837 Professional' or '837 Institutional' in the 'Billing Form' field.
4. Select 'Sort File' in the 'Billing Options' field.
5. Enter/select 837 Professional/837 Institutional file sorting criteria.
6. Click 'Process' button to sort/generate 837 Professional/837 Institutional file.
7. Select 'Run Report' in the 'Billing Options' field.
8. Select 'Print' in the 'Print Or Delete Report' field.
9. Select 837 Professional/837 Institutional file sorted which includes services(s), and click 'Process' button to display 837 Professional/837 Institutional outbound file report.
10. For service codes/dates of service not included/designated in Authorization requirements for selected 837 Guarantor (via 'Guarantor/Payors' form, 'Authorization Information' section):
11. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file report - In case where no Managed Care Authorization or Payor Based Authorization record exists for client/service(s) to be included in 837 file, ensure that Authorization-related error is not reported/included for service(s) in 'Required Data Missing: Patient Service Data' (837 Professional) or 'Required Data Missing: Patient Claim Data' (837 Institutional) section of report, and service(s) is/are included in 837 file information without requirement for coverage by Managed Care Authorization/Payor Based Authorization record(s) (subject to all other 837 sorting criteria/requirements).
12. For service codes/dates of service designated to require Authorization for selected 837 Guarantor but where 'Require Authorization' field is set to 'No' (via 'Guarantor/Payors' form, 'Authorization Information' section):
13. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file report - In case where no Managed Care Authorization or Payor Based Authorization record exists for client/service(s) to be included in 837 file, ensure that Authorization-related error is not reported/included for service(s) in 'Required Data Missing: Patient Service Data' or 'Required Data Missing: Patient Claim Data' section of report, and service(s) is/are included in 837 file information without requirement for coverage by Managed Care Authorization/Payor Based Authorization record(s) (subject to all other 837 sorting criteria/requirements).
14. For service codes/dates of service designated to require Authorization for selected 837 Guarantor and where 'Require Authorization' field is set to 'Yes' (via 'Guarantor/Payors' form, 'Authorization Information' section):
15. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file report - In case where no Managed Care Authorization record exists for client/service(s) to be included in 837 file and no Payor Based Authorization record exists for service(s) to be included in 837 file, ensure that error is reported/included for service(s) in 'Required Data Missing: Patient Service Data' or 'Required Data Missing: Patient Claim Data' section of report.
16. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file report - In case where Managed Care Authorization record exists for client/service(s) to be included in 837 file but is exhausted/cannot be used for services (due to Available Dollars/Available Units/Available Visits limitations) and no Payor Based Authorization record exists for service(s) to be included in 837 file, ensure that error is reported/included for service(s) in 'Required Data Missing: Patient Service Data' or 'Required Data Missing: Patient Claim Data' section of report.
17. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file report - In case where Managed Care Authorization record exists for client/service(s) to be included in 837 file and is not exhausted/can be used for services, ensure that Authorization-related error is not reported/included for service(s) in 'Required Data Missing: Patient Service Data' or 'Required Data Missing: Patient Claim Data' section of report, and service(s) is/are included in 837 file information due to coverage by Managed Care Authorization record(s) (subject to all other 837 sorting criteria/requirements).
18. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file report - In case where no Managed Care Authorization record exists for client/service(s) to be included in 837 file but Payor Based Authorization record exists for service(s) to be included in 837 file, ensure that Authorization-related error is not reported/included for service(s) in 'Required Data Missing: Patient Service Data' or 'Required Data Missing: Patient Claim Data' section of report, and service(s) is/are included in 837 file information due to coverage by Payor Based Authorization record(s) (subject to all other 837 sorting criteria/requirements).
19. Notes for service code/date of service Authorization requirements outlined above:
20. 837 File Report Error Message Examples:
21. 'Authorizations On File For Guarantor Are Exhausted For Service Code: (CODE INFO) On Service Date: (DATE)'
22. 'Service Code (CODE) Is Missing An Authorization Number For Guarantor (GUARANTOR) For Date Of Service (DATE). No More Claims Processing Will Be Done For The Episode'
23. Service(s) may be excluded or included in 837 Professional/837 Institutional file where error is present, dependent on 'Verification Level For Authorizations For 837 Electronic Billing' configuration for applicable Guarantor (via Avatar Cal-PM 'Guarantors/Payors' form, 'Authorization Information' section).

• Avatar Appointment Scheduling must be installed
• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Require Authorizations At Guarantors/Payors Level' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' may optionally be enabled/disabled
• One or more Guarantor(s) where values are selected/defined for 'Verify Services and Appointments Against Available Authorizations' and 'Verification Level For Authorizations For Appointment Scheduling' fields (via Avatar Cal-PM 'Guarantors/Payors' form, 'Authorization Information' section)
• Client record eligible for Scheduling Calendar/Appointment Scheduling service entry where applicable Guarantor(s) is/are assigned via client Financial Eligibility record

1. Open Avatar Cal-PM 'Scheduling Calendar' form.
2. Select date and Practitioner for Appointment Scheduling entry; right click and select 'Add Appointment' action.
3. Enter/select values for 'Appointment Site', 'Appointment Date', 'Appointment Start Time', 'Duration', 'Appointment End Time', 'Service Code', 'Client' and 'Practitioner' fields.
4. For service codes/dates of service (Appointment date) not included/designated in Authorization requirements for applicable/liable Guarantor (via 'Guarantor/Payors' form, 'Authorization Information' section):
5. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/service criteria values and no Payor Based Authorization record exists in system applicable to Appointment/service criteria - Ensure that user is not presented with Error/Warning message and Appointment/service entry is allowed without requirement for coverage by Managed Care Authorization/Payor Based Authorization record(s).
6. For service codes/dates of service ('Appointment Date') designated to require Authorization for applicable/liable Guarantor but where 'Require Authorization' field is set to 'No' (via 'Guarantor/Payors' form, 'Authorization Information' section):
7. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/service criteria and no Payor Based Authorization record exists in system applicable to Appointment/service criteria- Ensure that user is not presented with Error/Warning message and Appointment/service entry is allowed without requirement for coverage by Managed Care Authorization/Payor Based Authorization record(s).
8. For service codes/dates of service (Appointment Date) designated to require Authorization for applicable/liable Guarantor and where 'Require Authorization' field is set to 'Yes' (via 'Guarantor/Payors' form, 'Authorization Information' section):
9. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/service criteria and no Payor Based Authorization record exists in system applicable to Appointment/service criteria - Ensure that user is presented with Error/Warning message noting 'No valid authorizations found on file.'
10. In case where Managed Care Authorization record exists for selected client applicable to Appointment/service criteria but is exhausted/cannot be used for additional services (due to Available Dollars/Available Units/Available Visits limitations), and no Payor Based Authorization record exists in system applicable to Appointment/service criteria - Ensure that user is presented with Error/Warning message noting 'Authorization On File For Guarantor Will Be Exhausted With Requested Services.'
11. In case where Managed Care Authorization record exists for selected client applicable to Appointment/service criteria and is not exhausted/can be used for additional services - Ensure that user is not presented with Error/Warning message and Service entry is allowed due to coverage by Managed Care Authorization record(s).
12. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/service criteria (or Managed Care Authorization record exists but is exhausted/cannot be used for additional services) but Payor Based Authorization record exists in system applicable to Appointment/service criteria - Ensure that user is not presented with Error/Warning message and Appointment/service entry is allowed due to coverage by Payor Based Authorization record(s).
13. Notes for service code/Appointment Date Authorization requirements outlined above:
14. If 'Require Authorization Number' field is set to 'Yes' for service code/date Authorization requirement (via 'Guarantor/Payors' form, 'Authorization Information' section), 'Authorization Number' value must also be filed/present for applicable Managed Care Authorization/Payor Based Authorization record for Appointment/service entry to be allowed without error.
15. For Managed Care Authorizations - Records/Authorizations applicable to 'Appointment Date' entry/value will be those where 'Appointment Date' is on or after 'Authorization Start Date' and on or before 'Authorization End Date' (including records where 'Appointment Date' is same as 'Authorization End Date').
16. For Payor Based Authorizations - Records/Authorizations applicable to 'Appointment Date' entry/value will be those where 'Appointment Date' is on or after 'Effective Date' and before 'Expiration Date' (not including records where 'Appointment Date' is same as 'Expiration Date'). If 'Expiration Date' is not defined, Payor Based Authorization will be considered applicable to all dates of service/Appointment dates on/after 'Effective Date'.
17. Appointment/service entry via 'Scheduling Calendar' form may be disallowed or allowed following error/warning message, dependent on 'Verification Level For Authorizations For Appointment Scheduling' configuration for applicable Guarantor (via Avatar Cal-PM 'Guarantors/Payors' form, 'Authorization Information' section).