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Avatar MSO 2022 Monthly Release 2022.03.00 Acceptance Tests

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Update 32 Summary | Details
Claim Processing Blackout
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • Service Authorization
  • Claim Processing Blackout
  • Batch Creation - Assign ID
  • Batch Creation
  • Claim Processing (CMS 1500)
  • Authorization Listing
  • Close Batch
Scenario 1: Claim Processing Blackout
Specific Setup:
  • Client: Identify a client that has a valid Service Authorization record.
  • Note the Client, Provider, Funding Source, and Authorization Number.
  • Claim Processing Blackout:
  • Add a blackout entry, noting the value selected in the following fields (if used):
  • Blackout Start Date, Blackout End Date, Client, Provider, Funding Source, and Authorization.
  • Batch Creation is used to create a new batch, Note the number.
  • Claim Processing (CMS 1500) or Claim Processing (UB-04) is used to create a date of service that is within the Blackout Start Date and Blackout End Date. Validate that the claim is denied due to the blackout.
  • Close Batch is used to close the batch.
Steps
  1. Open ‘Claim Processing Blackout’.
  2. Select ‘Add’ in ‘Add/Edit/Delete’.
  3. Create an entry that will overlap the entry created in setup.
  4. Validate that following message is displayed: Blackout cannot be filed because it overlaps with an existing blackout record for the same entities.
  5. Click [OK].
  6. Change the entries so that there is no overlap.
  7. Click [Submit].
  8. Click [Yes] to remain in the form.
  9. Select ‘Edit’ in ‘Add/Edit/Delete’.
  10. Select the ‘Blackout Record’ that was just created.
  11. Edit any field.
  12. Click [Submit].
  13. Click [Yes] to remain in the form.
  14. Select ‘Edit’ in ‘Add/Edit/Delete’.
  15. Select the ‘Blackout Record’ that was just edited.
  16. Validate that the data that was changed was retained.
  17. Select ‘Delete’ in ‘Add/Edit/Delete’.
  18. Select the ‘Blackout Record’ that was created in setup.
  19. Validate that the claim that was denied displays in ‘Previously Denied Services For Retro Adjudication’. Select the claim.
  20. Select the desired ‘Adjustment Code’.
  21. Click [Submit].
  22. Validate that following message is displayed: There are services selected for retro adjudication. Are you sure you want to continue?
  23. Click [Yes].
  24. Click [Yes] to remain in the form.
  25. Select ‘Edit’ in ‘Add/Edit/Delete’.
  26. Validate that the deleted ‘Blackout Record’ is no longer displayed in the ‘Blackout Record’ field.
  27. Close the form.
Topics
• Claims Processing • NX
Update 33 Summary | Details
Avatar MSO/ProviderConnect Claims Pre-Adjudication
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Billing - Bill Generation section
  • Billing - Unsubmitted Bill
  • View Bill Pre-adjudication Results
Scenario 1: Avatar MSO 'Claims Pre-Adjudication' - Processing/Transmission of Pre-Adjudication Information to ProviderConnect
Specific Setup:
  1. Netsmart ProviderConnect (or other application utilizing the Avatar MSO 'Claim Pre-Adjudication' web service/process)
  2. Client record eligible for Claim/Service entry in Avatar MSO and Netsmart ProviderConnect
  3. Claims Pre-Adjudication Submission data submitted via Netsmart ProviderConnect to be Pre-Adjudicated automatically by Avatar MSO background process
Steps
  1. Enter one or more services via Netsmart ProviderConnect 'Treatment' service entry.
  2. Navigate to ProviderConnect 'Billing' menu.
  3. Click 'Generate Bill' button for selected criteria.
  4. Click 'Click 'Submit Bill for Pre-adjudication' button for ProviderConnect billing transaction.
  5. The Avatar MSO Pre-Adjudication processing will be performed by a system background process automatically, starting every 30 minutes and processing any new/previously unprocessed services; accordingly, wait for sufficient time frame for Pre-Adjudication to be performed by Avatar MSO.
  6. Within 'Unsubmitted Bills' section of ProviderConnect 'Billing' menu, navigate to bill created above which was submitted for Pre-Adjudication.
  7. Click 'View Pre-adjudication Results' button for unsubmitted bill.
  8. Following Avatar MSO Pre-Adjudication processing of services, ensure that 'Status' value in ProviderConnect is updated from 'Queued' to either 'Passed Edit' or 'Failed Edit'. ('Passed Edit' or 'Failed Edit' Pre-Adjudication status for each service will be determined by Avatar MSO using the same configurations/criteria/logic as standard Claim Processing service adjudication for 'Approved' and 'Denied'/'Pending' claim status (respectively).)
  9. Following Avatar MSO Pre-Adjudication processing of services, ensure that services with 'Status' value of 'Failed Edit' also include data for 'Pre-Adjudication Edit Failed Reason' in ProviderConnect display. ('Pre-Adjudication Edit Failed Reason values for 'Failed Edit' services will be determined by Avatar MSO using the same configurations/criteria/logic as standard Claim Processing service adjudication for the 'Explanation of Coverage' detailed message.)
Topics
• Claims Processing