Avatar Cal-PM 2022 Update 9

1. Open 'Registry Settings' form.
2. Enter search value 'Enable Payor Based Authorizations' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable Payor Based Authorizations' is returned (under 'Avatar PM -> Services -> Payor Based Authorizations' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting 'Y' adds the form 'Payor Based Authorizations' to the menu. This form allows the user to file authorizations for a particular guarantor and service combination. These authorizations will be used for all clients that do not have an authorization specified for that particular guarantor and service in the 'Managed Care Authorizations' form. Selecting 'N' will remove the form from the menu.

Please Note: This functionality is only applicable to 837 electronic billing."

1. Open 'Registry Settings' form.
2. Enter search value 'Enable CPT Based Payor Authorizations' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable CPT Based Payor Authorizations' is returned (under 'Avatar PM -> Services -> Payor Based Authorizations' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting 'Y' will remove 'Service Code' or 'Service Code(s)' field from the 'Payor Based Authorizations' form and replace it with the 'Select CPT Codes' button, which will allow users to define payor-based authorizations based on a service's relevant CPT code as defined in 'Service Fee/Cross Reference Maintenance'.

Selecting 'N' will revert back to service code based payor authorizations."

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• 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. 'Service Code' (Not available when Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled)
6. 'Effective Date'
7. 'Expiration Date'
8. 'Authorization Number'
9. 'Display Authorizations' Button
10. 'Select Authorizations To Edit/Delete' Button
11. 'Select CPT Codes' Button (Available only when Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled)
12. 'All CPT Codes' (Available only when Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' is enabled)
13. Enter/select values for all required/desired fields for Payor Based Authorization record/entry.
14. 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').
15. Click 'Submit' button to file 'Payor Based Authorizations' form/record.
16. 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.
17. Ensure all field values are present in 'Payor Based Authorizations' form/record as previously entered/filed.
18. Click 'Display Authorizations' button to display the Payor Based Authorizations report/information.
19. 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:
20. 'Guarantor'
21. 'Service Code' or 'CPT Code' (Dependent on Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations')
22. 'Program' (To be employed by future Avatar Cal-PM update - Will display 'All Programs (NONE)' in report information)
23. 'Practitioner Category' (To be employed by future Avatar Cal-PM update - Will display 'All Practitioner Categories (NONE)' in report information)
24. 'Effective Date'
25. Expiration Date'
26. 'Authorization Number'
27. Open Crystal Reports or other SQL reporting tool.
28. 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.
29. 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.

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' must be 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

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. 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.'
6. 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')
7. Note - 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)
8. 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.'
9. 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')
10. Note - 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)
11. 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).
12. 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')

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' must be 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. (Note, acceptance testing may also be confirmed via Avatar Cal-PM 'Quick Billing' form/functionality.)
2. Select '837 Professional' or '837 Institutional' in the 'Billing Form' field.
3. Select 'Sort File' in the 'Billing Options' field.
4. Enter/select 837 Professional/837 Institutional file sorting criteria.
5. Click 'Process' button to sort/generate 837 Professional/837 Institutional file.
6. Select 'Run Report' in the 'Billing Options' field.
7. Select 'Print' in the 'Print Or Delete Report' field.
8. Select 837 Professional/837 Institutional file sorted which includes services(s), and click 'Process' button to display 837 Professional/837 Institutional outbound file report.
9. 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' (837 Professional) or 'Required Data Missing: Patient Claim Data' (837 Institutional) section of report.
10. Error Message Examples:
11. 'Authorizations On File For Guarantor Are Exhausted For Service Code: (CODE INFO) On Service Date: (DATE)'
12. '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'
13. Note - 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)
14. 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' (837 Professional) or 'Required Data Missing: Patient Claim Data' (837 Institutional) section of report.
15. Note - 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)
16. 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' (837 Professional) or 'Required Data Missing: Patient Claim Data' (837 Institutional) section of report, and service(s) is/are included in 837 file information as expected (subject to all other 837 sorting criteria/requirements).

• Avatar Appointment Scheduling must be installed
• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' must be 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. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/service criteria/entry values and no Payor Based Authorization record exists in system applicable to Appointment/service criteria/entry values - Ensure that user is presented with Error/Warning message noting 'No valid authorizations found on file.'
5. For Payor Based Authorizations - Records/Authorizations applicable to 'Date Of Service'/Appointment Date 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')
6. Note - 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)
7. In case where Managed Care Authorization record exists for selected client applicable to Appointment/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 Appointment/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.'
8. For Payor Based Authorizations - Records/Authorizations applicable to 'Date Of Service'/Appointment Date 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')
9. Note - 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)
10. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/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 Appointment/service criteria/entry values - 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).
11. For Payor Based Authorizations - Records/Authorizations applicable to 'Date Of Service'/Appointment Date 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')

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' must be enabled
• One or more Service Codes where 'CPT-4/HCPCS Code' value is defined for Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form)
• 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

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. 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.'
6. 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')
7. For CPT Based Payor Authorizations - Records/Authorizations applicable to service criteria/entry values will be determined by the selected Service Code for Client Charge Input and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'
8. Note - 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)
9. 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.'
10. 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')
11. For CPT Based Payor Authorizations - Records/Authorizations applicable to service criteria/entry values will be determined by the selected Service Code for Client Charge Input and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'
12. Note - 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)
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. 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')
15. For CPT Based Payor Authorizations - Records/Authorizations applicable to service criteria/entry values will be determined by the selected Service Code for Client Charge Input and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'

• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' must be enabled
• One or more Service Codes where 'CPT-4/HCPCS Code' value is defined for Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form)
• 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. (Note, acceptance testing may also be confirmed via Avatar Cal-PM 'Quick Billing' form/functionality.)
2. Select '837 Professional' or '837 Institutional' in the 'Billing Form' field.
3. Select 'Sort File' in the 'Billing Options' field.
4. Enter/select 837 Professional/837 Institutional file sorting criteria.
5. Click 'Process' button to sort/generate 837 Professional/837 Institutional file.
6. Select 'Run Report' in the 'Billing Options' field.
7. Select 'Print' in the 'Print Or Delete Report' field.
8. Select 837 Professional/837 Institutional file sorted which includes services(s), and click 'Process' button to display 837 Professional/837 Institutional outbound file report.
9. 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' (837 Professional) or 'Required Data Missing: Patient Claim Data' (837 Institutional) section of report.
10. Error Message Examples:
11. 'Authorizations On File For Guarantor Are Exhausted For Service Code: (CODE INFO) On Service Date: (DATE)'
12. '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'
13. For CPT Based Payor Authorizations - Records/Authorizations applicable to service(s) to be included in 837 file will be determined by the Service Code and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'
14. Note - 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)
15. 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' (837 Professional) or 'Required Data Missing: Patient Claim Data' (837 Institutional) section of report.
16. For CPT Based Payor Authorizations - Records/Authorizations applicable to service(s) to be included in 837 file will be determined by the Service Code and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'
17. Note - 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)
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' (837 Professional) or 'Required Data Missing: Patient Claim Data' (837 Institutional) section of report, and service(s) is/are included in 837 file information as expected (subject to all other 837 sorting criteria/requirements).
19. For CPT Based Payor Authorizations - Records/Authorizations applicable to service(s) to be included in 837 file will be determined by the Service Code and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'

• Avatar Appointment Scheduling must be installed
• Avatar Cal-PM Registry Setting 'Enable Payor Based Authorizations' must be enabled
• Avatar Cal-PM Registry Setting 'Enable CPT Based Payor Authorizations' must be enabled
• One or more Service Codes where 'CPT-4/HCPCS Code' value is defined for Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form)
• 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. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/service criteria/entry values and no Payor Based Authorization record exists in system applicable to Appointment/service criteria/entry values - Ensure that user is presented with Error/Warning message noting 'No valid authorizations found on file.'
5. For Payor Based Authorizations - Records/Authorizations applicable to 'Date Of Service'/Appointment Date 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')
6. For CPT Based Payor Authorizations - Records/Authorizations applicable to Appointment/service criteria/entry values will be determined by the selected Service Code for Appointment/service and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'
7. Note - 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)
8. In case where Managed Care Authorization record exists for selected client applicable to Appointment/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 Appointment/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.'
9. For Payor Based Authorizations - Records/Authorizations applicable to 'Date Of Service'/Appointment Date 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')
10. For CPT Based Payor Authorizations - Records/Authorizations applicable to Appointment/service criteria/entry values will be determined by the selected Service Code for Appointment/service and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'
11. Note - 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)
12. In case where no Managed Care Authorization record exists for selected client applicable to Appointment/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 Appointment/service criteria/entry values - 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. For Payor Based Authorizations - Records/Authorizations applicable to 'Date Of Service'/Appointment Date 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')
14. For CPT Based Payor Authorizations - Records/Authorizations applicable to Appointment/service criteria/entry values will be determined by the selected Service Code for Appointment/service and the 'CPT-4/HCPCS Code' value assigned to this Service Code (via Avatar Cal-PM 'Service Fee/Cross Reference Maintenance' form) where CPT Code is also included/authorized in the 'Select CPT Codes' section of Payor Based Authorization record, and/or Payor Based Authorization records where 'All CPT Codes' field is set to 'Yes'