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Avatar MSO 2022 Monthly Release 2022.01.01 Acceptance Tests

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Update 4 Summary | Details
Avatar MSO 'Claim Processing Automation' form.
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Professional Automated Processing
  • 837 Health Care Claim Institutional Automated Processing
Scenario 1: Automated 837 Inbound Processing/Claim Processing Automation - Verification of 837 Processing
Specific Setup:
  • Avatar MSO Automated Claim Processing functionality must be enabled and configured for system (via 'Import/Export File Configuration' form)
  • Avatar MSO Automated Claim Processing functionality may optionally be configured to automatically close batch(es) after 837 posting, create Vouchers and/or create EOBs (via 'Claim Processing Automation' form)
  • Inbound 837 Professional and/or Institutional format files for automated processing containing one or more valid claims/services
Steps
  1. Place multiple 837 Professional and/or Institutional inbound files in 'Processing' directories for Claims Processing Automation (as defined in the 'Import/Export File Configuration' form).
  2. Ensure Avatar MSO Automated Claims Processing function for 837 Professional and Institutional files loads, compiles and posts each 837 inbound file in 'Processing' directories.
  3. Ensure for all Claims Processing batches created via inbound 837 automated processing are closed automatically (as defined in the 'Claim Processing Automation' form). This can be confirmed via 'Close Batch' form, the 'Open Batches' Widget and/or by reviewing data in Avatar MSO SQL table 'SYSTEM.batch_current_data.'
  4. Ensure that inbound 837 automated processing completes for all 837 inbound files placed in 'Processing' directories, and that files are correctly moved to 'Processed' directories.
  5. Ensure that no system errors are recorded in the 'Error' file directory .txt file (as defined in the 'Import/Export File Configuration' form) for processed 837 inbound files.
  6. If 999 Functional Acknowledgement response files are configured for generation on 837 file automated processing - ensure that on inbound 837 file processing, 999 Functional Acknowledgement response file(s) are automatically generated on server in directory specified for 999 file creation in the 'Import/Export File Configuration' form.
  7. If 277CA Claim Acknowledgement response files are configured for generation on 837 file automated processing - ensure that on inbound 837 file processing, 277CA Claim Acknowledgement response file(s) are automatically generated on server in directory specified for 277CA file creation in the 'Import/Export File Configuration' form.
  8. If 835 Health Care Claim Payment/Advice response files are configured for generation on EOB creation - ensure that on EOB creation (manually via 'Create EOB' form or via automated claims processing functionality including scheduled EOB creation), 835 Health Care Claim Acknowledgement response file(s) are automatically generated on server in directory specified for 835 file creation in the 'Claim Processing Automation' form.
'837 Health Care Claim Professional' Form / '837 Health Care Claim Institutional' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Professional
  • 837 Health Care Claim Institutional
Scenario 1: '837 Health Care Claim Professional' - Verification of File Format Validation
Specific Setup:
  • Inbound 837 Professional format file where 'Functional Group Header - Application Sender's Code/Receiver's Code (GS-02/GS-03) and/or 'Transaction Set Control Number' (ST-02) values are not included
Steps
  1. Open '837 Health Care Claim Professional' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for inbound 837 Professional format file and click 'Process' button.
  4. Ensure user is presented with error dialog noting 'Missing Required Field / Invalid Format: APPLICATION SENDERS CODE = (Segment: GS - segment name Loop: 0)' / '...APPLICATION RECEIVERS CODE...' or 'Missing Required Field / Invalid Format: TRANSACTION SET CONTROL NUMBER = (Segment: ST - Transaction Set Loop: 0)' and the file is not successfully loaded.
  5. If Functional Acknowledgement (999) file is generated following 837 load attempt, ensure that file is reported as 'Rejected' (R) with Syntax Error Code 'One or More Segments in Error' (5) in 999 Functional Acknowledgement data (loop/segment 2110-IK5-01 'Transaction Set Acknowledgement Code' = 'R' and 'Syntax Error Code' = '5'; Example: IK5*R*5~AK9*R*1*1*0~).
Scenario 2: '837 Health Care Claim Institutional' - Verification of File Format Validation
Specific Setup:
  • Inbound 837 Institutional format file where 'Functional Group Header - Application Sender's Code/Receiver's Code (GS-02/GS-03) and/or 'Transaction Set Control Number' (ST-02) values are not included
Steps
  1. Open '837 Health Care Claim Institutional' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for inbound 837 Institutional format file and click 'Process' button.
  4. Ensure user is presented with error dialog noting 'Missing Required Field / Invalid Format: APPLICATION SENDERS CODE = (Segment: GS - segment name Loop: 0)' / '...APPLICATION RECEIVERS CODE...' or 'Missing Required Field / Invalid Format: TRANSACTION SET CONTROL NUMBER = (Segment: ST - Transaction Set Loop: 0)' and the file is not successfully loaded.
  5. If Functional Acknowledgement (999) file is generated following 837 load attempt, ensure that file is reported as 'Rejected' (R) with Syntax Error Code 'One or More Segments in Error' (5) in 999 Functional Acknowledgement data (loop/segment 2110-IK5-01 'Transaction Set Acknowledgement Code' = 'R' and 'Syntax Error Code' = '5'; Example: IK5*R*5~AK9*R*1*1*0~).
Avatar MSO 'Other EOB Information' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Other EOB Information
Scenario 1: 'Other EOB Information' - Form Verification
Specific Setup:
  • One or more existing EOB(s) to use in filing or importing 'Other EOB Information' data
  • Avatar MSO 'Other EOB Information' import file
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open 'Other EOB Information' form.
  2. For manual entry of 'Other EOB Information', select existing EOB and enter or clear 'Check/EFT Date', 'Check/EFT Number' and/or 'Check/EFT Amount' field values.
  3. Click 'Submit' button to file/save Other EOB Information.
  4. Select same existing EOB in 'Other EOB Information' form, and ensure that previously entered/filed field values are present, including values for 'Check/EFT Date', 'Check/EFT Number' and/or 'Check/EFT Amount' fields where added/updated or cleared.
  5. For import of 'Other EOB Information', navigate to 'Import Other EOB Information' section of form.
  6. Click 'Select Data Import File' button.
  7. Select 'Other EOB Information' import file containing valid EOB Info import data.
  8. Click 'Import Other EOB Information' button.
  9. For import of 'Other EOB Information' data, ensure that file import is completed in timely manner and confirmation dialog is presented on import filing completion.
  10. Open Crystal Reports or Other SQL tool.
  11. In Avatar MSO SQL table 'SYSTEM.table_eob_core', ensure that values in fields 'eob_check_date', 'eob_check_number' and/or 'eob_check_amount' (for 'Check/EFT Date', 'Check/EFT Number' and/or 'Check/EFT Amount' form fields, respectively) are updated/reflect most recent information from 'Other EOB Information' manual entry or import.
Topics
• 837 Health Care Claim Professional • Claims Processing • 837 Health Care Claim Institutional • NX • Create EOB
Update 7 Summary | Details
Avatar MSO to Avatar PM Service Filing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • MSO to Parent System Integration Mapping
  • Client Ledger
  • Create EOB
  • Other EOB Information
Scenario 1: Avatar MSO to PM Parent System Service Filing - Verification of Service Filing With 'Service Filing Inhibit Rule' Defined
Specific Setup:
  • 'File Services On Closing Of Batch Or Creation Of EOB' must be set to 'Yes' (via 'MSO to Parent System Integration Mapping' form)
  • Service Filing Inhibit Rule for 'Check Number For EOB' and/or 'EOB Creation' must be defined for Avatar MSO Contracting Provider (via 'MSO to Parent System Integration Mapping' form)
  • Client record with Avatar PM/Cal-PM episode(s) eligible for service filing
  • Client record with service(s) originating in Avatar MSO eligible for service filing to Avatar PM/Cal-PM
Steps
  1. Open Avatar MSO 'Close Batch' or 'Close Multiple Batches' form.
  2. Note - Acceptance Testing may also be confirmed via Avatar MSO 'Claim Processing Automation' functionality for automatic posting/closing 837 file batches
  3. Select Claims Processing batch(es) to be closed.
  4. Set 'Close Batch' field to 'Yes' and submit form to close batch(es).
  5. For clients with 'Approved' status services eligible for service filing to Avatar PM/Cal-PM and where 'Service Filing Inhibit Rule' is defined for Contracting Provider(s), ensure that service(s) are not filed/not present in Avatar PM/Cal-PM following 'Close Batch' action, pending EOB Creation and/or 'Check/EFT Number' entry for inclusive EOB.
  6. Service Filing Inhibition may be confirmed by service(s) not being included in Avatar PM/Cal-PM 'Client Ledger' display
  7. Service Filing Inhibition may also be confirmed via Avatar MSO SQL table 'SYSTEM.mso_to_pm_service_failed', with a row present for Claims Processing Batch ID/Service ID and error message 'Service will be held from filing into PM until it is placed on an EOB' or 'Service will be held from filing into PM due to lack of a check number'
  8. On inclusion of service(s) in Avatar MSO EOB and/or 'Check/EFT Number' entry for inclusive EOB, ensure that eligible service(s) are successfully filed to Avatar PM/Cal-PM.
  9. Service Filing may be confirmed by service(s) being included in Avatar PM/Cal-PM 'Client Ledger' display
  10. Service Filing may also be confirmed via Avatar MSO SQL table 'SYSTEM.mso_to_pm_service_failed', with a rows deleted for Claims Processing Batch ID/Service IDs previously filed due to Service Filing Inhibition
'Claim Entry' Web Service
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Claim Entry Web Service
Scenario 1: 'Claim Entry' Web Service - Verification of Claim/Service Filing
Specific Setup:
  • Client record eligible for Claim/Service entry in Avatar MSO and Netsmart ProviderConnect
  • Netsmart ProviderConnect (or other application utilizing the Avatar MSO 'Claim Entry' web service)
Steps
  1. Enter service(s) via Netsmart ProviderConnect 'Treatment' service entry.
  2. Navigate to ProviderConnect 'Billing' menu.
  3. Click 'Generate Bill' button for selected criteria.
  4. Click 'Submit Bill' button for ProviderConnect billing transaction (or file via other application utilizing the Avatar MSO 'Claim Entry' web service).
  5. In Avatar MSO, ensure that claims processing batch(es) are created/updated via the 'Claim Entry' web service/receipt of services from Netsmart ProviderConnect (this can be confirmed via 'Batch Creation' form and/or 'Open Batches' Widget).
  6. In Avatar MSO 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB04)' form, open created claims processing batch.
  7. Ensure that all claims/services are present/filed from ProviderConnect submitted 'Billing' data (or filed/confirmed via other application utilizing the Avatar MSO 'Claim Entry' web service).
Topics
• MSO To Parent System Integration Mapping • NX • Web Services
Update 8 Summary | Details
Avatar MSO 'Performing Provider Registration' Form.
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Performing Provider Registration
Scenario 1: 'Performing Provider Registration' - Form Verification
Specific Setup:
  • A 'Performing Provider Registration' exists that has data filed for all required fields and includes a date that was overlapping from a deleted registration date.
Steps
  1. Open Avatar MSO 'Performing Provider Registration' form.
  2. Click 'New Performing Provider' button to create new Performing Provider Registration (or search/select existing Performing Provider Registration record for edit).
  3. Enter/select values for 'Name', 'Registration Start Date' and any other Provider data fields as required/desired.
  4. Ensure 'Registration End State' is not specified.
  5. Select one or more values in 'Primary License Type for Claims' field.
  6. Select 'Create New' from the 'Primary License Type Effective Dates' field.
  7. Enter/select values for 'Effective Start Date', 'Primary License Type for Claims' fields.
  8. Click 'File Primary License Type Effective Date' button.
  9. Click 'Submit' button to file 'Performing Provider Registration' form.
  10. Open Avatar MSO 'Performing Provider Registration' form.
  11. Enter/select previously filed Performing Provider Registration record.
  12. Change 'Registration Start Date' to an earlier date.
  13. Click 'Primary License Type Effective Date' drop down. Select previously created row.
  14. Click 'Delete Primary License Type Effective Dates' button.
  15. Click 'Primary License Type Effective Date' drop down and Select 'Create New'.
  16. Enter same value as 'Registration Start Date' field into the 'Effective Start Date' field.
  17. Select 'Primary License Type for Claims' value.
  18. Click 'File Primary License Type Effective Date' button.
  19. Click 'Submit' button to file 'Performing Provider Registration' form.
  20. Open Avatar MSO 'Performing Provider Registration' form
  21. Enter/select previously filed Performing Provider Registration record.
  22. Enter date that overlaps with the previous Registration period in 'Registration End Date' field.
  23. Ensure “Already Active For This Date…Invalid Movement” error message is not displayed, and 'Registration End Date' is allowed.
'837 Health Care Claim Professional' Form / '837 Health Care Claim Institutional' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Professional
  • 837 Health Care Claim Institutional
Scenario 1: '837 Health Care Claim Professional' - Verification of Claim/Service Adjustment Filing
Specific Setup:
  • 837 Professional format inbound file for compilation and posting including one or more claims/services where '2430-CAS-02' value is blank.
Steps
  1. Open '837 Health Care Claim Professional' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for invalid inbound 837 Professional format file where '2430-CAS-02 value' is blank.
  4. Click 'Process' button
  5. Ensure error dialog is displayed with message: "Missing Required Field. Unable To Determine Loop Information. 1 - 2430 - CAS"
Scenario 2: '837 Health Care Claim Institutional' - Verification of Claim/Service Adjustment Filing
Specific Setup:
  • 837 Institutional format inbound file for compilation and posting including one or more claims/services where '2430-CAS-02' value is blank
Steps
  1. Open '837 Health Care Claim Institutional' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for invalid inbound 837 Institutional format file where '2430-CAS-02' value is blank.
  4. Click 'Process' button
  5. Ensure error dialog is displayed with message: "Missing Required Field. Unable To Determine Loop Information. 1 - 2430 - CAS"


Scenario 3: '837 Health Care Claim Professional' - Verification of Claim/Service Adjustment Filing
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled (set to '2')
  • Avatar MSO Registry Setting 'Adjudicate Batches' must be enabled (set to '2')
  • 'Crystal Reports' or other SQL reporting tool
  • 837 Professional format inbound file for compilation and posting including one or more valid claims/services with adjustment information included
Steps
  1. Open '837 Health Care Claim Professional' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for inbound 837 Professional format file and click 'Process' button.
  4. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
  5. Click 'Process' button.
  6. In 837 Professional Compile Report, ensure that claim/services are successfully compiled.
  7. Select 'Post File' in the 'Options' field, and select compiled 837 Professional file.
  8. Click 'Process' button.
  9. In 837 Professional Post Report, ensure that claim/services are successfully posted.
  10. Open 'Claim Processing (CMS 1500)' form.
  11. Select claims processing batch created via 837 Professional inbound posting.
  12. Navigate to 'Service Detail' section of form.
  13. Select service row and click 'Edit Service Information' to view service detail.
  14. Click the 'Enter Third Party Adjudication Data' button to view Third Party Payment/Other Healthcare Coverage information for selected service.
  15. Within Third Party Payment/Other Healthcare Coverage information display, click 'View' button to display/view Service Adjustment entries for selected service/Third Party Payment information.
  16. Confirm that service adjustment (CAS) values from 837 Professional inbound claim/service are displayed and present for selected service.
  17. Open 'Crystal Reports' or other SQL reporting tool.
  18. In Avatar MSO SQL table 'SYSTEM.mso_claim_adjustments', ensure that service adjustment(s) for posted 837 Professional claims/services is/are present in SQL table data.
Scenario 4: '837 Health Care Claim Institutional' - Verification of Claim/Service Adjustment Filing
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled (set to '2')
  • Avatar MSO Registry Setting 'Adjudicate Batches' must be enabled (set to '2')
  • 'Crystal Reports' or other SQL reporting tool
  • 837 Institutional format inbound file for compilation and posting including one or more valid claims/services with adjustment information included
Steps
  1. Open '837 Health Care Claim Institutional ' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for inbound 837 Institutional format file and click 'Process' button.
  4. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
  5. Click 'Process' button.
  6. In 837 Institutional Compile Report, ensure that claim/services are successfully compiled.
  7. Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
  8. Click 'Process' button.
  9. In 837 Institutional Post Report, ensure that claim/services are successfully posted.
  10. Open 'Claim Processing (UB-04)' form.
  11. Select claims processing batch created via 837 Institutional inbound posting.
  12. Navigate to 'Service Detail' section of form.
  13. Select service row and click 'Edit Service Information' to view service detail.
  14. Click the 'Enter Third Party Adjudication Data' button to view Third Party Payment/Other Healthcare Coverage information for selected service.
  15. Within Third Party Payment/Other Healthcare Coverage information display, click 'View' button to display/view Service Adjustment entries for selected service/Third Party Payment information.
  16. Confirm that service adjustment (CAS) values from 837 Institutional inbound claim/service are displayed and present for selected service.
  17. Open 'Crystal Reports' or other SQL reporting tool.
  18. In Avatar MSO SQL table 'SYSTEM.mso_claim_adjustments', ensure that service adjustment(s) for posted 837 Institutional claims/services is/are present in SQL table data.
Topics
• Performing Provider • NX • 837 Health Care Claim Professional • Claims Processing • 837 Health Care Claim Institutional
Update 12 Summary | Details
837 Health Care Claim Adjustment Posting
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Professional
  • 837 Health Care Claim Institutional
Scenario 1: '837 Health Care Claim Professional' - Verification of Claim/Service Adjustment Filing
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled (set to '2')
  • Avatar MSO Registry Setting 'Adjudicate Batches' must be enabled (set to '2')
  • 'Crystal Reports' or other SQL reporting tool
  • 837 Professional format inbound file for compilation and posting including one or more valid claims/services with adjustment information included
Steps
  1. Open '837 Health Care Claim Professional' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for inbound 837 Professional format file and click 'Process' button.
  4. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
  5. Click 'Process' button.
  6. In 837 Professional Compile Report, ensure that claim/services are successfully compiled.
  7. Select 'Post File' in the 'Options' field, and select compiled 837 Professional file.
  8. Click 'Process' button.
  9. In 837 Professional Post Report, ensure that claim/services are successfully posted.
  10. Open 'Claim Processing (CMS 1500)' form.
  11. Select claims processing batch created via 837 Professional inbound posting.
  12. Navigate to 'Service Detail' section of form.
  13. Select service row and click 'Edit Service Information' to view service detail.
  14. Click the 'Enter Third Party Adjudication Data' button to view Third Party Payment/Other Healthcare Coverage information for selected service.
  15. Within Third Party Payment/Other Healthcare Coverage information display, click 'View' button to display/view Service Adjustment entries for selected service/Third Party Payment information.
  16. Confirm that service adjustment (CAS) values from 837 Professional inbound claim/service are displayed and present for selected service.
  17. Open 'Crystal Reports' or other SQL reporting tool.
  18. In Avatar MSO SQL table 'SYSTEM.mso_claim_adjustments', ensure that service adjustment(s) for posted 837 Professional claims/services is/are present in SQL table data.
Scenario 2: '837 Health Care Claim Institutional' - Verification of Claim/Service Adjustment Filing
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled (set to '2')
  • Avatar MSO Registry Setting 'Adjudicate Batches' must be enabled (set to '2')
  • 'Crystal Reports' or other SQL reporting tool
  • 837 Institutional format inbound file for compilation and posting including one or more valid claims/services with adjustment information included
Steps
  1. Open '837 Health Care Claim Institutional ' form.
  2. Select 'Load File' in the 'Options' field.
  3. Enter file path for inbound 837 Institutional format file and click 'Process' button.
  4. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
  5. Click 'Process' button.
  6. In 837 Institutional Compile Report, ensure that claim/services are successfully compiled.
  7. Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
  8. Click 'Process' button.
  9. In 837 Institutional Post Report, ensure that claim/services are successfully posted.
  10. Open 'Claim Processing (UB-04)' form.
  11. Select claims processing batch created via 837 Institutional inbound posting.
  12. Navigate to 'Service Detail' section of form.
  13. Select service row and click 'Edit Service Information' to view service detail.
  14. Click the 'Enter Third Party Adjudication Data' button to view Third Party Payment/Other Healthcare Coverage information for selected service.
  15. Within Third Party Payment/Other Healthcare Coverage information display, click 'View' button to display/view Service Adjustment entries for selected service/Third Party Payment information.
  16. Confirm that service adjustment (CAS) values from 837 Institutional inbound claim/service are displayed and present for selected service.
  17. Open 'Crystal Reports' or other SQL reporting tool.
  18. In Avatar MSO SQL table 'SYSTEM.mso_claim_adjustments', ensure that service adjustment(s) for posted 837 Institutional claims/services is/are present in SQL table data.
Topics
• 837 Health Care Claim Professional • Claims Processing • NX