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Avatar Cal-PM 2023 Update 12

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Product Requirements / Recommendations

Avatar Cal-PM required
RADplus required

Product Update Form Description

The filing of Payments/Adjustments is updated to support Duration fields in the Avatar MSO 'Retro Claim Adjudication' form. The Duration fields are added in Avatar MSO 2021 Update 2.

Included Updates

None

Required Updates

None

Details
NEW1 CHANGED0 FIXED0
New (1)
Payment/Adjustment Posting and Avatar MSO 'Retro Claim Adjudication'
The filing of Payments/Adjustments is updated to support Duration fields in the Avatar MSO 'Retro Claim Adjudication' form.
Avatar MSO 'Retro Claim Adjudication' entries filed via Avatar Cal-PM payment/adjustment posting are updated to include 'Updated Duration' and 'Take Back Duration' Duration values. Note, Avatar MSO 2021 Update 2 is required for 'Original Duration', 'Updated Duration' and 'Take Back Duration' fields to be present in Avatar MSO 'Retro Claim Adjudication' form/SQL table.
Value Added: Adds support for Duration in Avatar MSO 'Retro Claim Adjudication' entries filed via Avatar Cal-PM payment/adjustment posting
Topics
• 835 Health Care Claim Payment/Advice • Individual Cash Posting • NX • Posting/Adjustment Codes • Spreadsheet Batch Remittance Posting • Spreadsheet Remittance Posting
 
Acceptance Tests
AV-85908 Summary | Details
Payment/Adjustment Posting and Avatar MSO 'Retro Claim Adjudication'
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Individual Cash Posting (PM)
  • Retro Claim Adjudication
  • 835 Health Care Claim Payment/Advice (PM)
Scenario 1: Avatar PM Service Payment/Adjustment Posting - Verification of Retro Claim Adjudication filing in Avatar MSO
Specific Setup:
  • One or more services which have been filed/pushed to Avatar PM parent system via Avatar MSO (and eligible for Retro Claim Adjudication entry in Avatar MSO)
  • 'Trigger Retro Claim Adjudication Entry in MSO' must be set to 'Yes' for one or more posting/adjustment codes (via Avatar PM 'Posting/Adjustment Codes Definition' form)
  • Extended Dictionary Data Element 'Payment/Adjustment And Transfer Codes (920)' may be defined with a PM posting/adjustment code in Avatar MSO 'Other Tabled Files' Indirect Dictionary Code 'Adjustment Code (351)' if default adjustment code not desired (via Avatar MSO 'Dictionary Update' form)
  • 'Default Retro Claim Adjudication Adjustment Code For Adjustments In PM' must be defined in Avatar MSO (via Avatar MSO 'Set System Defaults' form)
  • Avatar MSO 2021 Update 2 is required for 'Original Duration', 'Updated Duration' and 'Take Back Duration' fields to be present in Avatar MSO 'Retro Claim Adjudication' form/SQL table
Steps
  1. Open Avatar PM 'Individual Cash Posting' form.
  2. Note - functionality may also be confirmed via 'Spreadsheet Remittance Posting' and/or 'Batch Cash Posting' forms.
  3. Enter/select value for 'Client and 'Post By Claim Or Episode' fields (and 'Claim'/'Episode' fields if enabled).
  4. Click 'Select Item(s) To Post Against' button to open service selection grid.
  5. Select service for payment/adjustment posting and click 'OK' button to close service selection grid.
  6. Enter/select values for 'Posting Date', 'Date Of Receipt', and 'Guarantor' fields.
  7. Enter/select values for 'Dollar Amount To Be Posted' and 'Posting Code' fields.
  8. Enter/select value for 'Action For Remaining Balance If Applicable' (if required), and any other fields as required/desired.
  9. Click 'Update Temporary' file button to save payment/adjustment entry.
  10. Click 'Submit' button to file 'Individual Cash Posting' form and finalize temporary file posting/adjustment entries.
  11. Open Avatar MSO 'Retro Claim Adjudication' form.
  12. Note, Retro Claim Adjudication entries filed via Avatar PM payment/adjustment posting may also be confirmed directly in Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications'
  13. Select 'Edit' in 'Add/Edit/Delete Claim Adjudication' field.
  14. In 'Claim' dropdown selection field, ensure that new Retro Claim Adjudication is present for original Avatar MSO claim where payment/adjustment has been filed for service in Avatar PM.
  15. In 'Claim' and 'Date of Service/Procedure' dropdown selection fields, select original Avatar MSO claim/service where payment/adjustment has been filed for service in Avatar PM.
  16. Confirm Avatar MSO 'Adjustment Code' value for Retro Claim Adjudication entry is value linked to Avatar PM posting/adjustment code by Extended Dictionary Data Element 'Payment/Adjustment And Transfer Codes'; if no MSO value for 'Payment/Adjustment And Transfer Codes' link is defined, confirm 'Adjustment Code' value for Retro Claim Adjudication entry is value defined as 'Default Retro Claim Adjudication Adjustment Code For Adjustments In PM'.
  17. Confirm 'Take Back Amount' value for Retro Claim Adjudication entry is value filed for 'Dollar Amount To Be Posted' in Avatar PM.
  18. Confirm 'Updated Disbursement Amount' value for Retro Claim Adjudication entry is calculated as 'Original Disbursement Amount minus Take Back Amount'.
  19. Confirm 'Take Back Duration' value for Retro Claim Adjudication entry is calculated with same ratio as 'Updated Disbursement' to 'Original Disbursement'.
  20. Example 1
  21. 'Original Duration' = 120, 'Original Disbursement Amount' = 300
  22. 'Dollar Amount To Be Posted'/'Take Back Amount' = 150
  23. 'Take Back Duration' will be calculated as 60 (being 1/2 value of 'Original Duration', 1/2 ratio of 'Updated Disbursement Amount' to 'Original Disbursement Amount')
  24. Example 2
  25. 'Original Duration' = 60, 'Original Disbursement Amount' = 300
  26. 'Dollar Amount To Be Posted'/'Take Back Amount' = 300 (full adjustment/payment)
  27. 'Take Back Duration' will be calculated as 60 (being full take back 'Original Duration')
  28. Confirm 'Updated Duration' value for Retro Claim Adjudication entry is calculated as 'Original Duration minus Take Back Duration'.
  29. Close Avatar MSO 'Retro Claim Adjudication' form.
Scenario 2: '835 Health Care Claim Payment/Advice' - Verification of Retro Claim Adjudication filing in Avatar MSO for payment/adjustment
Specific Setup:
  • One or more claimed services which have been filed/pushed to Avatar PM parent system via Avatar MSO (eligible for Avatar PM 835 inbound posting and Retro Claim Adjudication entry in Avatar MSO)
  • 'Trigger Retro Claim Adjudication Entry in MSO' must be set to 'Yes' for one or more posting/adjustment codes (via Avatar PM 'Posting/Adjustment Codes Definition' form)
  • Extended Dictionary Data Element 'Payment/Adjustment And Transfer Codes (920)' may be defined with a PM posting/adjustment code in Avatar MSO 'Other Tabled Files' Indirect Dictionary Code 'Adjustment Code (351)' if default adjustment code not desired (via Avatar MSO 'Dictionary Update' form)
  • 'Default Retro Claim Adjudication Adjustment Code For Adjustments In PM' must be defined in Avatar MSO (via Avatar MSO 'Set System Defaults' form)
  • Avatar MSO 2021 Update 2 is required for 'Original Duration', 'Updated Duration' and 'Take Back Duration' fields to be present in Avatar MSO Retro Claim Adjudication form/SQL table
  • Inbound 835 Health Care Claim Payment/Advice file containing one or more successfully compiled entries for Avatar PM claims containing services originating in Avatar MSO
Steps
  1. Open Avatar PM '835 Health Care Claim Payment/Advice' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter 'File Path/Name' value for 835 inbound file to be loaded, and click 'Process File' button.
  4. Ensure 835 file is successfully loaded.
  5. Select 'Compile File' in the 'Options' field.
  6. Select loaded inbound 835 file in the 'Select File' field, and click 'Process File' button.
  7. In 835 Compile Report - ensure that payments/adjustments are successfully compiled for Avatar PM claims containing services originating in Avatar MSO.
  8. Select 'Post File' in the 'Options' field.
  9. Select compiled inbound 835 file in the 'Select File' field, enter values for 'Posting Date' and 'Date of Receipt' fields (as well as any other fields as required/desired), and click 'Process File' button.
  10. In 835 Posting Report - ensure that payments/adjustments are successfully posted for Avatar PM claims containing services originating in Avatar MSO.
  11. Open Avatar MSO 'Retro Claim Adjudication' form.
  12. Note, Retro Claim Adjudication entries filed via Avatar PM 835 payment/adjustment posting may also be confirmed directly in Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications'
  13. Select 'Edit' in 'Add/Edit/Delete Claim Adjudication' field.
  14. In 'Claim' dropdown selection field, ensure that new Retro Claim Adjudication is present for original Avatar MSO claim where payment/adjustment has been filed for service in Avatar PM via inbound 835 Health Care Claim Payment/Advice file posting.
  15. In 'Claim' and 'Date of Service/Procedure' dropdown selection fields, select original Avatar MSO claim/service where payment/adjustment has been filed for service in Avatar PM via inbound 835 Health Care Claim Payment/Advice file posting.
  16. Confirm Avatar MSO 'Adjustment Code' value for Retro Claim Adjudication entry is value linked to Avatar PM posting/adjustment code by Extended Dictionary Data Element 'Payment/Adjustment And Transfer Codes'; if no MSO value for 'Payment/Adjustment And Transfer Codes' link is defined, confirm 'Adjustment Code' value for Retro Claim Adjudication entry is value defined as 'Default Retro Claim Adjudication Adjustment Code For Adjustments In PM'.
  17. Confirm 'Take Back Amount' value for Retro Claim Adjudication entry is value filed for payment/adjustment in Avatar PM via inbound 835 Health Care Claim Payment/Advice file posting.
  18. Confirm 'Updated Disbursement Amount' value for Retro Claim Adjudication entry is calculated as 'Original Disbursement Amount minus Take Back Amount'.
  19. Confirm 'Take Back Duration' value for Retro Claim Adjudication entry is calculated with same ratio as 'Updated Disbursement' to 'Original Disbursement'.
  20. Example 1
  21. 'Original Duration' = 120, 'Original Disbursement Amount' = 300
  22. Amount posted from 835 adjustment/payment/'Take Back Amount' = 150
  23. 'Take Back Duration' will be calculated as 60 (being 1/2 value of 'Original Duration', 1/2 ratio of 'Updated Disbursement Amount' to 'Original Disbursement Amount')
  24. Example 2
  25. 'Original Duration' = 60, 'Original Disbursement Amount' = 300
  26. Amount posted from 835 adjustment/payment/'Take Back Amount' = 300 (full adjustment/payment)
  27. 'Take Back Duration' will be calculated as 60 (being full take back 'Original Duration')
  28. Confirm 'Updated Duration' value for Retro Claim Adjudication entry is calculated as 'Original Duration minus Take Back Duration'.
  29. Close Avatar MSO 'Retro Claim Adjudication' form.
Topics
• 835 Health Care Claim Payment/Advice • Individual Cash Posting • NX • Posting/Adjustment Codes • Spreadsheet Batch Remittance Posting • Spreadsheet Remittance Posting