Avatar Cal-PM 2024 Update 33

1. Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information.

"When this registry setting is set to "Y", when a batch is closed in Avatar MSO, each service in the batch that contains Other Healthcare Coverage and is pushed to Avatar Cal-PM will use the parent system service fee table to determine the Fee.

This also gives an end user the ability to override service charge and line adjustments within an 837I and 837P submission for MSO originating services that contain COB. This is accomplished by adding the field 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' to the 'Guarantor/Program Billing Defaults' form.

Entering "N" removes the Avatar MSO logic and the field from the form and disables Enable Override MSO Coordination of Benefits Service Charges and Line Adjustments logic in 837I and 837P submissions.

Upon product installation, the default setting will be "N"."

• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' must be enabled
• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information
• Avatar Cal-PM 'Guarantor/Program Billing Defaults Template' File Import file containing one or valid import rows for 837 Professional and/or 837 Institutional Defaults including 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field value ('Y' or 'N' value)
• Segment 141 for '837 Professional' defaults
• Segment 131 for '837 Institutional' defaults
• Updated import file layout document 'Avatar_Cal-PM_File_Import_Record_Layouts.xls' included with update package
• Crystal Reports or other SQL reporting tool

1. Open Avatar Cal-PM 'File Import' form.
2. Select File Type 'Guarantor/Program Billing Defaults'.
3. Select 'Upload New File' in 'Action' field and Click 'Process Action' button.
4. Select Avatar Cal-PM 'Guarantor/Program Billing Defaults' import file including one or more 837 Professional and/or 837 Institutional Defaults import rows and click 'Open' button.
5. Select 'Compile/Validate File' in 'Action' field.
6. Select loaded 'Guarantor/Program Billing Defaults' import file and click 'Process Action' button.
7. Ensure that 'Compile/Validate File' action completes, and message 'Compiled' or '(File Name) contains one or more errors. These errors can be reviewed using 'Print Errors' action' is displayed.
8. Click 'OK' button.
9. Select 'Print File' in 'Action' field to view successfully compiled import data; Select compiled import file and click 'Process Action' button.
10. In 'Guarantor/Program Billing Defaults' File Import Report, ensure that all valid import row(s) are included in report with segment/value details, including 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' fields.
11. Select 'Post File' in 'Action' field to post successfully compiled import data; Select compiled import file and click 'Process Action' button.
12. Ensure that 'Compile/Validate File' action completes, and message 'Posted' and/or 'The selected file contains one or more lines with compilation errors. Only those lines without compilation errors will be posted' is displayed.
13. Open Avatar Cal-PM 'Guarantor/Program Billing Defaults' form.
14. Select 'Edit Template' in 'Action' field and select imported Guarantor/Program Billing Defaults template for review/edit.
15. Navigate to '837 Professional' section of form.
16. Ensure that imported value for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present for selected template.
17. Navigate to '837 Institutional' section of form.
18. Ensure that imported value for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present for selected template.
19. Open Crystal Reports or other SQL reporting tool.
20. In Avatar Cal-PM SQL table 'SYSTEM.file_import_gpbdt_p837', ensure that value filed via import for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in 'ovd_mso_cob_chg_adj_code' / 'ovd_mso_cob_chg_adj_value' SQL table fields.
21. In Avatar Cal-PM SQL table 'SYSTEM.file_import_gpbdt_i837', ensure that value filed via import for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in 'ovd_mso_cob_chg_adj_code' / 'ovd_mso_cob_chg_adj_value' SQL table fields.

• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' must be enabled
• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information
• Crystal Reports or other SQL reporting tool

1. Open Avatar Cal-PM 'Guarantor/Program Billing Defaults' form.
2. Select 'Add Template' in 'Action field (or 'Edit Template' and select existing Guarantor/Program Billing Defaults template for review/edit).
3. Navigate to '837 Professional' section of form.
4. Ensure 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in '837 Professional' section of form; ensure User Help information (lightbulb icon) is included for field, containing the following information:
5. "When "Yes" is selected, the Cal-PM Service Fee associated with the service will post as the Service Line Item Charge Amount. To balance the claim, the system will identify the difference and insert either an OA*23 or OA*94 claim line adjustment segment."
6. Select value for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field (and any other fields/sections as desired).
7. Navigate to '837 Institutional' section of form.
8. Ensure 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in '837 Institutional' section of form; ensure User Help information (lightbulb icon) is included for field, containing the following information:
9. "When "Yes" is selected, the Cal-PM Service Fee associated with the service will post as the Service Line Item Charge Amount. To balance the claim, the system will identify the difference and insert either an OA*23 or OA*94 claim line adjustment segment."
10. Select value for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field (and any other fields/sections as desired).
11. Click 'Submit' button to file Guarantor/Program Billing Defaults template.
12. Select 'Edit Template' in 'Action field and select previously filed Guarantor/Program Billing Defaults template for review/edit.
13. Navigate to '837 Professional' section of form.
14. Ensure that previously selected/filed value for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in '837 Professional' section for selected template.
15. Navigate to '837 Institutional' section of form.
16. Ensure that previously selected/filed value for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in '837 Institutional' section for selected template.
17. Open Crystal Reports or other SQL reporting tool.
18. In Avatar Cal-PM SQL table 'SYSTEM.table_837_p_facility_prov_num', ensure that value filed for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in 'ovd_mso_cob_chg_adj_code' / 'ovd_mso_cob_chg_adj_value' SQL table fields.
19. In Avatar Cal-PM SQL table 'SYSTEM.table_837_i_facility_prov_num', ensure that value filed for 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field is present in 'ovd_mso_cob_chg_adj_code' / 'ovd_mso_cob_chg_adj_value' SQL table fields.

• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' must be enabled
• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information
• Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be set to use Parent System Service Fee Table (set to '0' or '4')
• If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined to use 'Parent System Service Fee Table' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• One or more 'Approved' status Avatar MSO services eligible for filing to parent Avatar Cal-PM system and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Close Batch' form.
2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar Cal-PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar Cal-PM system.
6. Open 'Client Ledger' form in parent Avatar Cal-PM system.
7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
8. Select 'Claim/Episode/All Episodes' value.
9. Select 'Ledger Type' value.
10. Click 'Process' button.
11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
12. For services originating via Avatar MSO and filed to Avatar Cal-PM parent system (where Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' is enabled):
13. Services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM Client Ledger 'Charge' value for service(s) reflects the applicable Cal-PM Service Fee Table Amount for service(s)
14. Note - Avatar Cal-PM 'Cost of Service'/'Guarantor Liability' value for service(s) originating in Avatar MSO with Other Healthcare Coverage information will reflect full Cal-PM Service Fee Table Amount, not including 'Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM
15. Note - Third Party Payment/Adjustment 'Other Healthcare Coverage' information from Avatar MSO will be stored with Cal-PM parent service to ensure correctly balanced Avatar Cal-PM outbound 837 claim information where Other Healthcare Coverage information is included in original claim/service (via SQL tables noted below)
16. Services not including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM 'Charge'/'Cost Of Service' (as well as 'Guarantor Liability') value for service(s) in Avatar Cal-PM reflects the applicable Cal-PM Service Fee Table Amount
17. Open Crystal Reports or other SQL reporting tool.
18. In Avatar Cal-PM SQL table 'SYSTEM.mso_service_cob', ensure that claim/service Third Party Payer 'Other Healthcare Coverage' filed with service via Avatar MSO is present.
19. Note - Avatar Cal-PM instance of SQL table 'SYSTEM.mso_service_cob' will on be populated with data where Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' is enabled
20. In Avatar Cal-PM SQL table 'SYSTEM.mso_claim_adjustments', ensure that claim/service Third Party Adjustment 'Other Healthcare Coverage' filed with service via Avatar MSO is present.
21. Note - Avatar Cal-PM instance of SQL table 'SYSTEM.mso_claim_adjustments' will on be populated with data where Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' is enabled

• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' must be enabled
• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information
• Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be set to use Parent System Service Fee Table (set to '0' or '4')
• If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined to use 'Parent System Service Fee Table' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• One or more services originating in Avatar MSO and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information

1. Open Avatar Cal-PM 'Client Ledger' form.
2. Select 'Client ID' value for client where services originating in Avatar MSO and including Other Healthcare Coverage information exist.
3. Select 'Claim/Episode/All Episodes' value (and enter/edit 'From Date'/'To Date' values if desired).
4. Select 'Ledger Type' value.
5. Click 'Process' button.
6. Where 'Simple' is selected for 'Ledger Type' - In 'Client Ledger' form display data, ensure that services originating in Avatar MSO and including Other Healthcare Coverage information reflect full Cal-PM Service Fee Table Amount, not including 'Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM.
7. Where 'Crystal' is selected for 'Ledger Type' - ensure that new/specific version of Client Ledger report is launched. ('Avatar_Cal_PM_Client_Ledger_Screen_Imbed_OHC_Chg_Adj', used only where Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' is enabled)
8. In Client Ledger Crystal Report data, ensure that for services originating in Avatar MSO and including Other Healthcare Coverage information, the 'Full Charge' value for service(s) full Cal-PM Service Fee Table Amount, not including 'Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM.
9. In Client Ledger Crystal Report data, click on 'Date of Service' to expand service information sub-report.
10. In Client Ledger Crystal Report data, ensure that for services originating in Avatar MSO and including Other Healthcare Coverage information, including the following fields (information from Avatar Cal-PM SQL tables 'SYSTEM.mso_service_cob' / 'SYSTEM.mso_claim_adjustments'):
11. 'Third Party Payer Name'
12. 'Third Party Payer Claim Amount'
13. 'Third Party Payer Paid Amount'
14. 'Third Party Payer Adjustment'
15. 'Third Party Remittance Date'

• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' must be enabled
• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information
• Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
• Avatar Cal-PM Registry Setting 'Add Support For Client Other Healthcare Coverage' may optionally be enabled (for 837 reporting of manually entered Avatar MSO services with Service-Level Third Party Payment/Adjustment 'Other Healthcare Coverage' information)
• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be set to use Parent System Service Fee Table (set to '0' or '4')
• If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined to use 'Parent System Service Fee Table' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• 'Include Service Level Adjudication Information (2430)' field must be set to 'Yes' in Avatar Cal-PM 'Guarantor/Program Billing Defaults' form ('837 Professional' section) for applicable Guarantor/Program
• 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field must be set to 'Yes' in Avatar Cal-PM 'Guarantor/Program Billing Defaults' form ('837 Professional' section) for applicable Guarantor/Program
• One or more service(s) eligible for Avatar Cal-PM 837 Professional file inclusion (via 'Electronic Billing' form) originating in Avatar MSO and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information

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 in 'Billing Form' field.
4. Enter/select 837 file sorting criteria, using values which will include service(s) originating in Avatar MSO.
5. Click 'Process' button to sort/generate 837 Professional file.
6. Select 'Dump File' in the 'Billing Options' field (or select 'Create File On Server' to review output file directly).
7. Select 'Print' in the 'Print Or Delete Report' field.
8. Select 837 Professional file sorted which includes services originating in Avatar MSO, and click 'Process' button to display 837 outbound file data.
9. In Avatar Cal-PM 837 Professional format outbound electronic billing file data - for services originating via Avatar MSO and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information:
10. Ensure that 2300-CLM Total Claim Charge Amount reflects the sum of Cal-PM Service Fee Table Amounts for all service(s) included in claim
11. Ensure that the following claim information payer loops reflect Third Party Payor 'Other Healthcare Coverage' information from originating Avatar MSO inbound claim (or Avatar Cal-PM 'Client Other Healthcare Coverage' form information for manually entered Avatar MSO services):
12. Other Subscriber Information (2320)
13. Other Insurance Coverage Information (2320)
14. Other Subscriber Name (2330A)
15. Other Payer Name (2330B)
16. Ensure that 2400-SV1 Line Item Charge Amount reflects the Cal-PM Service Fee Table Amount for service(s) included in claim
17. Ensure that 2430-SVD Line Adjudication Information/Service Line Paid Amount reflects Third Party Payment 'Other Healthcare Coverage' information from originating Avatar MSO inbound claim or manual entry
18. Ensure that 2430-CAS Line Adjustment entries reflect Third Party Adjustment 'Other Healthcare Coverage' information from originating Avatar MSO inbound claim or manual entry (Claim Adjustment Group Code/Claim Adjustment Reason Code/Adjustment Amount)
19. In case where there is a difference between 2400-SV1 Line Item Charge Amount for claim and sum of 2430-SVD Paid Amount/2430-CAS Line Adjustment Amounts, ensure that an additional 2430-CAS Line Adjustment entry is inserted by Avatar Cal-PM system to ensure claim total balancing and allow 837 inclusion
20. In case where this difference is positive, ensure that system-generated 2430-CAS Line Adjustment entry includes Claim Adjustment Group Code 'OA' and Claim Adjustment Reason Code '23' (with claim charge amount difference as Adjustment Amount; Example: 'CAS*OA*23*10~')
21. In case where this difference is negative, ensure that system-generated 2430-CAS Line Adjustment entry includes Claim Adjustment Group Code 'OA' and Claim Adjustment Reason Code '94' (with claim charge amount difference as Adjustment Amount; Example: 'CAS*OA*94*-10~')

• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' must be enabled
• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information
• Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
• Avatar Cal-PM Registry Setting 'Add Support For Client Other Healthcare Coverage' may optionally be enabled (for 837 reporting of manually entered Avatar MSO services with Service-Level Third Party Payment/Adjustment 'Other Healthcare Coverage' information)
• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be set to use Parent System Service Fee Table (set to '0' or '4')
• If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined to use 'Parent System Service Fee Table' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• 'Include Service Level Adjudication Information (2430)' field must be set to 'Yes' in Avatar Cal-PM 'Guarantor/Program Billing Defaults' form ('837 Institutional' section) for applicable Guarantor/Program
• 'Override MSO Coordination of Benefits Service Charges and Line Adjustments' field must be set to 'Yes' in Avatar Cal-PM 'Guarantor/Program Billing Defaults' form ('837 Institutional' section) for applicable Guarantor/Program
• One or more service(s) eligible for Avatar Cal-PM 837 Institutional file inclusion (via 'Electronic Billing' form) originating in Avatar MSO and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information

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 Institutional in 'Billing Form' field.
4. Enter/select 837 file sorting criteria, using values which will include service(s) originating in Avatar MSO.
5. Click 'Process' button to sort/generate 837 Institutional file.
6. Select 'Dump File' in the 'Billing Options' field (or select 'Create File On Server' to review output file directly).
7. Select 'Print' in the 'Print Or Delete Report' field.
8. Select 837 Institutional file sorted which includes services originating in Avatar MSO, and click 'Process' button to display 837 outbound file data.
9. In Avatar Cal-PM 837 Institutional format outbound electronic billing file data - for services originating via Avatar MSO and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information:
10. Ensure that 2300-CLM Total Claim Charge Amount reflects the sum of Cal-PM Service Fee Table Amounts for all service(s) included in claim
11. Ensure that the following claim information payer loops reflect Third Party Payor 'Other Healthcare Coverage' information from originating Avatar MSO inbound claim (or Avatar Cal-PM 'Client Other Healthcare Coverage' form information for manually entered Avatar MSO services):
12. Other Subscriber Information (2320)
13. Other Insurance Coverage Information (2320)
14. Other Subscriber Name (2330A)
15. Other Payer Name (2330B)
16. Ensure that 2400-SV2 Line Item Charge Amount reflects the Cal-PM Service Fee Table Amount for service(s) included in claim
17. Ensure that 2430-SVD Line Adjudication Information/Service Line Paid Amount reflects Third Party Payment 'Other Healthcare Coverage' information from originating Avatar MSO inbound claim or manual entry
18. Ensure that 2430-CAS Line Adjustment entries reflect Third Party Adjustment 'Other Healthcare Coverage' information from originating Avatar MSO inbound claim or manual entry (Claim Adjustment Group Code/Claim Adjustment Reason Code/Adjustment Amount)
19. In case where there is a difference between 2400-SV2 Line Item Charge Amount for claim and sum of 2430-SVD Paid Amount/2430-CAS Line Adjustment Amounts, ensure that an additional 2430-CAS Line Adjustment entry is inserted by Avatar Cal-PM system to ensure claim total balancing and allow 837 inclusion
20. In case where this difference is positive, ensure that system-generated 2430-CAS Line Adjustment entry includes Claim Adjustment Group Code 'OA' and Claim Adjustment Reason Code '23' (with claim charge amount difference as Adjustment Amount; Example: 'CAS*OA*23*10~')
21. In case where this difference is negative, ensure that system-generated 2430-CAS Line Adjustment entry includes Claim Adjustment Group Code 'OA' and Claim Adjustment Reason Code '94' (with claim charge amount difference as Adjustment Amount; Example: 'CAS*OA*94*-10~')