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Avatar MSO 2022 Monthly Release 2022.02.00 Acceptance Tests

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Update 9 Summary | Details
Avatar MSO Retro Claim Adjudication File Import
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • File Import
  • File Import - Error Report
  • Retro Claim Adjudication
Scenario 1: 'File Import' - Verification of '[Avatar MSO] Retro Claim Adjudication' Import
Specific Setup:
  • Client with claim(s)/services eligible for Retro Claim Adjudication entry/import in Avatar MSO, where two or more services exist in same/single claim
  • Avatar MSO 'Retro Claim Adjudication' Import File containing one or more valid import rows
Steps
  1. Open 'File Import' form in Avatar PM.
  2. Select File Type '[Avatar MSO] Retro Claim Adjudication'.
  3. Select 'Upload New File' in 'Action' field and Click 'Process Action' button.
  4. Select Avatar MSO 'Retro Claim Adjudication' import file and click 'Open' button.
  5. Select 'Compile/Validate File' in 'Action' field.
  6. Select loaded Retro Claim Adjudication 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.
  10. Select compiled Retro Claim Adjudication import file and click 'Process Action' button to view report.
  11. In File Import 'Print File' report, ensure that valid Retro Claim Adjudication entries are successfully compiled/included in report, including case where 'Add' Retro Claim Adjudication entries are included for same claim but different/multiple services in single import file.
  12. Select 'Print Errors' in 'Action' field.
  13. Select compiled Retro Claim Adjudication import file and click 'Process Action' button to view report.
  14. In File Import 'Print Errors' report, ensure that invalid Retro Claim Adjudication entries are displayed with error message/detail, including case where duplicate/multiple 'Add' Retro Claim Adjudication entries exist for same claim/service in single import file.
  15. Note - Duplicate/multiple Retro Claim Adjudication 'Add' entries for same claim/service in single import file are invalid and will be reported with error condition "Duplicate add record for same batch/claim/service disallowed. This line will be skipped."
  16. Select 'Post File' in 'Action' field.
  17. Select compiled Retro Claim Adjudication import file and click 'Process Action' button.
  18. Ensure that 'Post' 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.
  19. Open Avatar MSO 'Retro Claim Adjudication' form.
  20. Select 'Edit' in the 'Add/Edit/Delete Claim Adjudication' field to view imported Retro Claim Adjudication entries.
  21. Select 'Claim' and 'Date of Service/Procedure' value for imported Retro Claim Adjudication review.
  22. Ensure that Retro Claim Adjudication field values ('Take Back Amount', 'Take Back Units', 'Updated Disbursement Amount', 'Adjustment Code', etc.) reflect information filed via 'File Import' form, including case where 'Add' Retro Claim Adjudication entries were imported/posted for same claim but different/multiple services in single import file.
Topics
• Retro Claim Adjudication • File Import
Update 14 Summary | Details
Avatar MSO 'Void Claim Assignment' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Void Claim Assignment
  • Retro Claim Adjudication
Scenario 1: 'Void Claim Assignment' - Form Verification
Specific Setup:
  • Client with claim(s)/services eligible for Retro Claim Adjudication entry in Avatar MSO (where no previous 'Void' Retro Claim Adjudication entry has been filed)
Steps
  1. Open Avatar MSO 'Void Claim Assignment' form (under 'Avatar MSO / Claims Processing' menu).
  2. Ensure that the following fields are present in 'Void Claim Assignment' form:
  3. 'From Date Of Service'
  4. Begin date of service to include for Void service selection; Required
  5. 'Through Date Of Service'
  6. Begin date of service to include for Void service selection; Required
  7. 'Client ID'
  8. Client ID for Void service selection; Required
  9. 'Contracting Provider'
  10. Contracting Provider for Void service selection filtering; Optional
  11. 'Contracting Provider Program'
  12. Contracting Provider Program for Void service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
  13. 'Select Services To Void' button
  14. 'File' button
  15. Enter value for 'From Date Of Service' and 'Through Date of Service' criteria fields.
  16. Ensure that if date span for 'From Date Of Service'/'Through Date of Service' is greater than 365 days, user is presented with an error dialog noting 'Selected Time Period cannot exceed a 365 day period' and the criteria entry is disallowed.
  17. Enter/select value for 'Client ID' criteria field.
  18. Enter/select value for 'Contracting Provider' criteria field if desired.
  19. Select value for 'Contracting Provider Program' criteria field if desired.
  20. Click 'Select Services To Void' button to display Void service selection dialog for service selection criteria entered.
  21. Ensure that 'Select Service(s) To Void' service selection dialog displays all service(s) in 'Closed' status Avatar MSO Claim Processing batch(es) for the selected client/service dates (and 'Contracting Provider'/'Contracting Provider Program' if specified) where no previous 'Void' Retro Claim Adjudication entry has been filed for service.
  22. If no eligible services are found for selected client/service dates (and 'Contracting Provider'/'Contracting Provider Program' if specified), ensure that user is presented with error dialog noting 'No Services Found' on clicking 'Select Services To Void' button.
  23. In the 'Select Service(s) To Void' dialog, ensure that all service(s) meeting service selection criteria are displayed for selection with the following information for each service:
  24. 'Batch'
  25. 'Contracting Provider'
  26. 'Date Of Service'
  27. 'Claim #'
  28. 'Procedure Code'
  29. 'Charges'
  30. 'Total Disbursement'
  31. Select one or more service(s) for 'Void' Retro Claim Adjudication entry (using checkbox selection field for each desired service).
  32. Click 'OK' button in the 'Select Service(s) To Void' to complete Void service selection.
  33. Click 'File' button in 'Void Claim Assignment' form to file 'Void' (full takeback) Retro Claim Adjudication entry for each/all selected service(s).
  34. Ensure user is presented with a 'Void Services' confirmation dialog noting 'Selected services will be voided. Continue?'; Click 'Yes' button to proceed with Void Claim Assignment service filing.
  35. On Void Claim Assignment filing, ensure user is presented with a confirmation dialog noting 'Filed'; click 'OK' button to close confirmation dialog.
  36. Re-enter/re-select values for 'From Date Of Service'/'Through Date of Service' and 'Client ID' Void service selection criteria fields (along with 'Contracting Provider'/'Contracting Provider Program' if desired); Click 'Select Services To Void' button for Void service selection dialog display.
  37. Ensure that 'Select Service(s) To Void' service selection dialog excludes any service(s) where previous 'Void' Retro Claim Adjudication entry has been filed for service.
Scenario 2: 'Void Claim Assignment' - Verification of Retro Claim Adjudication Entries for Voided Services
Specific Setup:
  • Client with claim(s)/services eligible for Retro Claim Adjudication entry in Avatar MSO (where no previous 'Void' Retro Claim Adjudication entry has been filed)
Steps
  1. Open Avatar MSO 'Void Claim Assignment' form.
  2. Enter value for 'From Date Of Service' and 'Through Date of Service' fields.
  3. Enter/select value for 'Client ID' field.
  4. Enter/select value for 'Contracting Provider' (and 'Contracting Provider Program') criteria field if desired.
  5. Click 'Select Services To Void' button to display Void service selection dialog for service selection criteria entered.
  6. Select one or more service(s) for 'Void' Retro Claim Adjudication entry (using checkbox selection field for each desired service).
  7. Click 'OK' button in the 'Select Service(s) To Void' to complete Void service selection.
  8. Click 'File' button in 'Void Claim Assignment' form to file 'Void' (full takeback) Retro Claim Adjudication entry for each/all selected service(s).
  9. Ensure user is presented with a 'Void Services' confirmation dialog noting 'Selected services will be voided. Continue?'; Click 'Yes' button to proceed with Void Claim Assignment service filing.
  10. On Void Claim Assignment filing, ensure user is presented with a confirmation dialog noting 'Filed'; click 'OK' button to close confirmation dialog.
  11. Open Avatar MSO 'Retro Claim Adjudication' form.
  12. Note, Retro Claim Adjudication entries filed via the 'Void Claim Assignment' form may also be confirmed directly via Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications'
  13. Select 'Edit' in 'Add/Edit/Delete Claim Adjudication' field.
  14. In 'Claim' field, select claim including service(s) where Void entry was filed via 'Void Claim Assignment' form.
  15. In 'Date Of Service/Procedure' field, select service where Void entry was filed via 'Void Claim Assignment' form.
  16. In 'Retro Claim Adjudication' form, ensure that 'Void' (full takeback) Retro Claim Adjudication information exists for selected Claim/Service where 'Void' entry was filed via 'Void Claim Assignment' form, with information/values as follows:
  17. 'Updated Disbursement Amount' = 0
  18. 'Updated Approved Units' = 0
  19. 'Take Back Amount' = 'Original Disbursement Amount'
  20. 'Take Back Units' = 'Original Approved Units'
  21. 'Adjustment Code' contains code/value defined as system default Adjustment Code for Void
  22. Default Adjustment Code defined via Avatar MSO 'Set System Defaults' form, 'Default Retro Claim Adjudication Adjustment Code For 837 Professional Voids' / 'Default Retro Claim Adjudication Adjustment Code For 837 Institutional Voids' fields
  23. 'Comments' field for 'Void' Retro Claim Adjudication entry filed via 'Void Claim Assignment' form contains comment entry 'Retro rate adjustment created because of a void generated by the 'Void Claim Assignment' form'
Topics
• Retro Claim Adjudication • NX
Update 17 Summary | Details
Avatar MSO Budget Tracking
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Budget Tracking Account Setup
  • Retro Claim Adjudication
  • Delete Services
Scenario 1: 'Budget Tracking Account Setup' - Verification of Retro Claim Adjudication Entries
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Budget Tracking' must be enabled (Setting 'YC')
  • One or more Budget Tracking Account/Account Level entries for Authorization/service association
  • Client with 'Closed' status claim(s)/service(s) eligible for Retro Claim Adjudication entry in Avatar MSO, associated to existing Budget Tracking Account/Account Level entry
Steps
  1. Open Avatar MSO 'Budget Tracking Account Setup' form.
  2. Select 'Account' value for existing Budget Tracking Account view/update.
  3. On selection of existing Budget Tracking Account, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for all defined Account Levels, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Levels (from service 'Expected Disbursement' values).
  4. Select the 'Account Level' value for existing Budget Tracking Account Level view/update.
  5. On selection of Budget Tracking Account Level, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for selected Account Level, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Level (from service 'Expected Disbursement' values).
  6. Close (or submit/file) 'Budget Tracking Account Setup' form.
  7. Open Avatar MSO 'Retro Claim Adjudication' form.
  8. Note, Retro Claim Adjudication entry may also be created/confirmed via 837 Health Care Claim Professional/Institutional 'Void' and/or 'Replacement' claim posting.
  9. Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field (or 'Edit' to update existing Retro Claim Adjudication entry).
  10. Select 'Claim' and 'Date of Service/Procedure' value for Retro Claim Adjudication entry/update, selecting claim/service associated to Budget Tracking Account/Account Level.
  11. Enter value(s) for 'Updated Approved Units' and/or 'Updated Duration' fields, and calculate or directly update 'Updated Disbursement Amount' field.
  12. Allow system-calculation of updated values or directly enter values for 'Take Back Amount', 'Take Back Units' and/or 'Take Back Duration' fields.
  13. Select value for 'Adjustment Code' field if not defaulted automatically.
  14. Enter value in 'Comments' field for service/Retro Claim Adjudication entry.
  15. Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
  16. Close 'Retro Claim Adjudication' form (or repeat/file additional Retro Claim Adjudication entries as desired).
  17. Open Avatar MSO 'Budget Tracking Account Setup' form.
  18. Select 'Account' value for existing Budget Tracking Account view/update (selecting Account Level with associated service(s) where Retro Claim Adjudication entries exist).
  19. On selection of existing Budget Tracking Account, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for all defined Account Levels, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Levels (from service 'Expected Disbursement' values).
  20. Ensure that 'Summary' field 'Amount Remaining' values for selected Budget Tracking Account reflect 'Take Back Amount' values filed for Retro Claim Adjudication entries.
  21. Example:
  22. Budget Tracking Account Level 'Amount' value = $1000
  23. Two services claimed/associated to Account Level; Expected Disbursement for each service = $250 ($500 total for two services)
  24. Budget Tracking Account Level 'Amount Remaining' value = $500
  25. Retro Claim Adjudication entered for one claimed/associated service; Retro Claim Adjudication 'Take Back Amount' = $250
  26. Budget Tracking Account Level 'Amount Remaining' value = $750
  27. Select the 'Account Level' value for existing Budget Tracking Account Level view/update (selecting Account Level with associated service(s) where Retro Claim Adjudication entries exist).
  28. On selection of Budget Tracking Account Level, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for selected Account Level, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Level.
  29. Ensure that 'Summary' field 'Amount Remaining' value for selected Budget Tracking Account Level reflects 'Take Back Amount' values filed for Retro Claim Adjudication entries.
  30. Close (or submit/file) 'Budget Tracking Account Setup' form.
Scenario 2: 'Budget Tracking Account Setup' - Verification of Deleted Services
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Budget Tracking' must be enabled (Setting 'YC')
  • One or more Budget Tracking Account/Account Level entries for Authorization/service association
  • Client with 'Closed' status claim(s)/service(s) eligible for service deletion in Avatar MSO
Steps
  1. Open Avatar MSO 'Budget Tracking Account Setup' form.
  2. Select 'Account' value for existing Budget Tracking Account view/update.
  3. On selection of existing Budget Tracking Account, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for all defined Account Levels, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Levels (from service 'Expected Disbursement' values).
  4. Select the 'Account Level' value for existing Budget Tracking Account Level view/update.
  5. On selection of Budget Tracking Account Level value, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for selected Account Level, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Level (from service 'Expected Disbursement' values).
  6. Close (or submit/file) 'Budget Tracking Account Setup' form.
  7. Open Avatar MSO 'Delete Services' form.
  8. Enter/select client for service deletion in the 'Select Member' field.
  9. Select service for deletion in 'Select Service To Delete' field.
  10. Submit 'Delete Services' form to delete selected service.
  11. Open Avatar MSO 'Budget Tracking Account Setup' form.
  12. Select 'Account' value for existing Budget Tracking Account view/update (selecting Account with previously associated service(s) that have been deleted).
  13. On selection of existing Budget Tracking Account, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for all defined Account Levels, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Levels (from service 'Expected Disbursement' values).
  14. Ensure that 'Summary' field 'Amount Remaining' value for selected Budget Tracking Account reflects any deleted services previously associated to Account Levels.
  15. Example:
  16. Budget Tracking Account Level 'Amount' value = $1000
  17. Two services claimed/associated to Account Level; Expected Disbursement value for each service = $250 ($500 total for two services)
  18. Budget Tracking Account Level 'Amount Remaining' value = $500
  19. One claimed/associated service deleted; deleted Expected Disbursement value = $250
  20. Budget Tracking Account Level 'Amount Remaining' value = $750
  21. Select the 'Account Level' value for existing Budget Tracking Account Level view/update (selecting Account Level with previously associated service(s) that have been deleted).
  22. On selection of Budget Tracking Account Level value, ensure 'Summary' field in 'Account Levels' sub-section of form is populated with/displays existing values for selected Account Level, including 'Claimed' amount and 'Amount Remaining' values for existing 'Approved' status services associated to Account Level.
  23. Ensure that 'Summary' field 'Amount Remaining' value for selected Budget Tracking Account Level reflects any deleted services previously associated to Account Level.
  24. Close (or submit/file) 'Budget Tracking Account Setup' form.
Topics
• Retro Claim Adjudication • NX • Budget Tracking
Update 18 Summary | Details
'Electronic Billing' Support for Services Originating in Avatar MSO
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Electronic Billing
  • 837 Health Care Claim Institutional
  • Client Other Healthcare Coverage
Scenario 1: 'Electronic Billing' - Verification of 2320 AMT Values in 837 Professional (Services Originating in Avatar MSO)
Specific Setup:
  • Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
  • Avatar Cal-PM Registry Setting 'Include Service Level Adjudication Info' must be enabled (and 'Include Service Level Adjudication Information (2430)' field set to 'Yes' via 'Guarantor/Program Billing Defaults' form '837 Professional' section for applicable Guarantor/Program)
  • Avatar Cal-PM Registry Setting 'Include Patient Remaining Liability' must be enabled (and 'Select Type Of Information To Include In Patient Remaining Liability' field defined via 'Guarantor/Program Billing Defaults' form '837 Professional' section for applicable Guarantor/Program)
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
  • One or more service(s) eligible for Avatar Cal-PM 837 Professional file inclusion (via 'Electronic Billing' form) originating in Avatar MSO inbound 837 file processing and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
Steps
  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' in the 'Billing Form' field.
  3. Select 'Sort File' in the 'Billing Options' field.
  4. Enter/select 837 Professional file sorting criteria.
  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(s) originating via Avatar MSO inbound 837 claim(s), and click 'Process' button to display 837 Professional outbound file data.
  9. In Avatar PM 837 Professional format outbound electronic billing file data - for services originating via Avatar MSO inbound 837 file claims including 'Other Healthcare Coverage' information where 2320-AMT Coordination Of Benefits (COB) Payer Paid Amount value is present in original inbound 837 claim, ensure that 2320-AMT Coordination Of Benefits (COB) Payer Paid Amount loop/segment value is present and reflects same/original Avatar MSO 'Other Healthcare Coverage' inbound 837 claim value.
  10. Example: AMT*D*2~
  11. In Avatar PM 837 Professional format outbound electronic billing file data - for services originating via Avatar MSO inbound 837 file claims including 'Other Healthcare Coverage' information where 2320-AMT Remaining Patient Liability Amount value is present in original inbound 837 claim, ensure that 2320-AMT Remaining Patient Liability Amount loop/segment is present and reflects same/original Avatar MSO 'Other Healthcare Coverage' inbound 837 claim value.
  12. Example: AMT*EAF*58~
Scenario 2: 'Electronic Billing' - Verification of 2320 AMT Values in 837 Institutional (Services Originating in Avatar MSO)
Specific Setup:
  • Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
  • Avatar Cal-PM Registry Setting 'Include Service Level Adjudication Info' must be enabled (and 'Include Service Level Adjudication Information (2430)' field set to 'Yes' via 'Guarantor/Program Billing Defaults' form '837 Institutional' section for applicable Guarantor/Program)
  • Avatar Cal-PM Registry Setting 'Include Patient Remaining Liability' must be enabled (and 'Select Type Of Information To Include In Patient Remaining Liability' field defined via 'Guarantor/Program Billing Defaults' form '837 Institutional' section for applicable Guarantor/Program)
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
  • One or more service(s) eligible for Avatar Cal-PM 837 Institutional file inclusion (via 'Electronic Billing' form) originating in Avatar MSO inbound 837 file processing and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
Steps
  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 Institutional' in the 'Billing Form' field.
  3. Select 'Sort File' in the 'Billing Options' field.
  4. Enter/select 837 Institutional file sorting criteria.
  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(s) originating via Avatar MSO inbound 837 claim(s), and click 'Process' button to display 837 Institutional outbound file data.
  9. In Avatar PM 837 Institutional format outbound electronic billing file data - for services originating via Avatar MSO inbound 837 file claims including 'Other Healthcare Coverage' information where 2320-AMT Coordination Of Benefits (COB) Payer Paid Amount value is present in original inbound 837 claim, ensure that 2320-AMT Coordination Of Benefits (COB) Payer Paid Amount loop/segment value is present and reflects same/original Avatar MSO 'Other Healthcare Coverage' inbound 837 claim value.
  10. Example: AMT*D*2~
  11. In Avatar PM 837 Institutional format outbound electronic billing file data - for services originating via Avatar MSO inbound 837 file claims including 'Other Healthcare Coverage' information where 2320-AMT Remaining Patient Liability Amount value is present in original inbound 837 claim, ensure that 2320-AMT Remaining Patient Liability Amount loop/segment is present and reflects same/original Avatar MSO 'Other Healthcare Coverage' inbound 837 claim value.
  12. Example: AMT*EAF*58~
Scenario 3: 'Electronic Billing' - Verification of 'Add Support For Client Other Healthcare Coverage' Registry Setting (Services Originating in Avatar MSO)
Specific Setup:
  • Avatar Cal-PM Registry Setting 'Include Service Level Adjudication Info' must be enabled (and 'Include Service Level Adjudication Information (2430)' field set to 'Yes' via 'Guarantor/Program Billing Defaults' form '837 Professional' and/or '837 Institutional' section for applicable Guarantor/Program)
  • Avatar Cal-PM Registry Setting 'Add Support For Client Other Healthcare Coverage' must be enabled
  • 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
  • One or more service(s) eligible for Avatar Cal-PM 837 Professional/837 Institutional file inclusion (via 'Electronic Billing' form) originating in Avatar MSO and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
Steps
  1. Open Avatar 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 'Billing Form' field.
  3. Enter/select 837 file sorting criteria, using values which will include service(s) originating in Avatar MSO.
  4. Click 'Process' button to sort/generate 837 Professional or 837 Institutional file.
  5. Select 'Dump File' in the 'Billing Options' field (or select 'Create File On Server' to review output file directly).
  6. Select 'Print' in the 'Print Or Delete Report' field.
  7. Select 837 Professional/837 Institutional file sorted which includes services originating in Avatar MSO, and click 'Process' button to display 837 outbound file data.
  8. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file data - for services originating via Avatar MSO manual entry and including Service-Level Third Party Payment/Adjustment 'Other Healthcare Coverage' information (but where Claim-Level Other Healthcare Coverage/Third Party Payer Information was not entered), ensure that the following 837 Loop/Segments are included with values defined in Avatar Cal-PM 'Client Other Healthcare Coverage' record(s) for client/episode:
  9. Other Subscriber Information (2320)
  10. From 'Client Other Healthcare Coverage' form 'Subscriber Group Name', 'Insurance Type Code' and 'Claim Filing Indicator Code' fields
  11. Other Insurance Coverage Information (2320)
  12. From 'Client Other Healthcare Coverage' form 'Subscriber Assignment Of Benefits' and 'Subscriber Release Of Info' fields
  13. Other Subscriber Name (2330A)
  14. From 'Client Other Healthcare Coverage' form 'Subscriber's Name' and 'Subscriber Policy #' fields
  15. Other Payer Name (2330B)
  16. From 'Client Other Healthcare Coverage' form 'Guarantor Name' and 'Guarantor Payer Identifier' fields
  17. Notes:
  18. The Avatar Cal-PM 'Client Other Healthcare Coverage' record applicable to claims/services originating via Avatar MSO manual entry will be determined by 'Payer Identifier' value entered for MSO Service-Level Third Party Payment/Adjustment 'Other Healthcare Coverage' service information - this value must match the 'Guarantor Payer Identifier' value entered in 'Client Other Healthcare Coverage' record for the above 837 segments/information to be included in 837 claims
  19. The Avatar Cal-PM 'Client Other Healthcare Coverage' record applicable to claim/services originating via Avatar MSO manual entry will be determined by service date(s) compared to 'Effective Date' / 'Expiration Date' values entered in 'Client Other Healthcare Coverage' record
  20. If no Avatar Cal-PM 'Client Other Healthcare Coverage' record is found applicable to claim/service originating via Avatar MSO manual entry (based on 'Guarantor Payer Identifier' and 'Effective Date'/'Expiration Date' values) the 2320/2330A/2330B loops/segments noted above will not be included in Avatar Cal-PM 837 Professional/Institutional claim
  21. Other Subscriber Address 2330A segments are suppressed when Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' is enabled and the claim/service being included in 837 file through 'Electronic Billing' is using Other Healthcare Coverage from MSO
Scenario 4: 'Electronic Billing' - Verification of 'Support MSO Other Healthcare Coverage' Registry Setting (Services Originating in Avatar MSO With Incomplete OHC Information)
Specific Setup:
  • Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
  • Avatar Cal-PM Registry Setting 'Include Service Level Adjudication Info' must be enabled (and 'Include Service Level Adjudication Information (2430)' field set to 'Yes' via 'Guarantor/Program Billing Defaults' form '837 Professional' and/or '837 Institutional' section for applicable Guarantor/Program)
  • Avatar Cal-PM Registry Setting 'Include Patient Remaining Liability' must be enabled (and 'Select Type Of Information To Include In Patient Remaining Liability' field defined via 'Guarantor/Program Billing Defaults' form '837 Professional' and/or '837 Institutional' section for applicable Guarantor/Program)
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
  • One or more service(s) eligible for Avatar Cal-PM 837 Professional/837 Institutional file inclusion (via 'Electronic Billing' form) originating in Avatar MSO and including incomplete Third Party Payment/Adjustment 'Other Healthcare Coverage' information
  • Example: Service-level Third Party Payment/Adjustments entered for service in Avatar MSO but with no value for 'Payer Identifier'
Steps
  1. Open Avatar 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 'Billing Form' field.
  3. Enter/select 837 file sorting criteria, using values which will include service(s) originating in Avatar MSO.
  4. Click 'Process' button to sort/generate 837 Professional or 837 Institutional file.
  5. Ensure 837 generation process is completed and user is presented with 'Compile Complete' dialog message.
  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 originating in Avatar MSO, and click 'Print 837 Report' button to display 837 outbound file report.
  9. In 'Electronic Billing' 837 Professional and/or 837 Institutional report display, ensure that 837 compilation errors are present for services originating in Avatar MSO and including incomplete Third Party Payment/Adjustment 'Other Healthcare Coverage' information; Errors can be reviewed under the 'Required Data Missing: Patient Claim Data', 'Required Data Missing: Patient Service Data' and/or 'Required Data Missing: Other Data' sub-reports/sections.
  10. 837 Electronic Billing Error Examples:
  11. Missing Field/Invalid Format: Name Last Or Org. Name (Loop: 2330A Segment: NM1 Iteration: 1)
  12. Unable To Create Segment: NM1 (Loop: 2330A) / Unable To Create Loop: 2330A
  13. Missing Field/Invalid Format: Name Last Or Org. Name (Loop: 2330B Segment: NM1 Iteration: 1)
  14. Unable To Create Segment: NM1 (Loop: 2330B) / Unable To Create Loop: 2330B
  15. Select 'Dump File' in the 'Billing Options' field (or select 'Create File On Server' to review output file directly).
  16. Select 'Print' in the 'Print Or Delete Report' field.
  17. Select 837 Professional/837 Institutional file sorted which includes services originating in Avatar MSO, and click 'Process' button to display 837 outbound file data.
  18. In Avatar Cal-PM 837 Professional/837 Institutional format outbound electronic billing file data - for services originating via Avatar MSO manual entry and including incomplete Service-Level Third Party Payment/Adjustment 'Other Healthcare Coverage' information as noted above, ensure that claims are successfully created (without incomplete/missing data loops from 837 error reports where non-required elements).
Topics
• Electronic Billing • Claims Processing • NX