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Avatar MSO 2022 Monthly Release 2022.03.02 Acceptance Tests

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Update 26 Summary | Details
Avatar MSO 'Enable Service Times' Registry Setting
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • CPT Code Definition (MSO)
  • Claim Processing (CMS 1500)
  • Claim Processing with Override (CMS 1500)
  • Claim Processing (UB-04)
  • Claim Processing with Override (UB-04)
  • Revenue Code Definition (MSO)
  • Fast Service Entry Submission
  • Fast Service Entry
Scenario 1: 'Claim Processing (CMS 1500)' - Verification Of Service Time Fields
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Service Times' must be enabled
  • CPT Code Definition where 'Require Service Time' is set to 'Yes' (via Avatar MSO 'CPT Code Definition' form)
  • Client record(s) valid for Service Entry/Claim Processing
Steps
  1. Open Avatar MSO 'Claim Processing (CMS 1500)' form (or 'Claim Processing (CMS 1500) With Override' form).
  2. Select claims processing batch for service entry/edit.
  3. Open existing claim or create new claim for service entry/edit.
  4. Enter/select value for 'Member Name or ID' and 'Provider' fields in claim level section of form.
  5. Navigate to 'Service Detail' section of form.
  6. Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
  7. Enter/select 'Date of Service' field value.
  8. Enter/select 'Procedure Code' field value.
  9. If 'Require Service Time' is set to 'Yes' for CPT Code entered/selected in 'Procedure Code' field, ensure that 'Service Start Time' and 'Service End Time' fields are enabled and required in form.
  10. If 'Require Service Time' is set to 'No' for CPT Code entered/selected in 'Procedure Code' field (or no value is defined), ensure that 'Service Start Time' and 'Service End Time' fields are disabled (and not required in form).
  11. Enter/select values for all required/desired fields in form (including 'Service Start Time' and 'Service End Time' fields if applicable).
  12. Click 'Submit' button to file 'Claim Processing (CMS 1500)' form (or 'Claim Processing (CMS 1500) With Override' form).
Scenario 2: 'Claim Processing (UB-04)' - Verification Of Service Time Fields
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Service Times' must be enabled
  • Revenue Code Definition where 'Require Service Time' is set to 'Yes' (via Avatar MSO 'Revenue Code Definition' form)
  • Client record(s) valid for Service Entry/Claim Processing
Steps
  1. Open Avatar MSO 'Claim Processing (UB-04)' form (or 'Claim Processing (UB-04) With Override' form).
  2. Select claims processing batch for service entry/edit.
  3. Open existing claim or create new claim for service entry/edit.
  4. Enter/select value for 'Member Name or ID' and 'Provider' fields in claim level section of form.
  5. Navigate to 'Service Detail' section of form.
  6. Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
  7. Enter/select 'Date of Service' field value.
  8. Enter/select 'Revenue Code' field value.
  9. If 'Require Service Time' is set to 'Yes' for Revenue Code entered/selected in 'Revenue Code' field, ensure that 'Service Start Time' and 'Service End Time' fields are enabled and required in form.
  10. If 'Require Service Time' is set to 'No' for Revenue Code entered/selected in 'Revenue Code' field (or no value is defined), ensure that 'Service Start Time' and 'Service End Time' fields are disabled (and not required in form).
  11. Enter/select values for all required/desired fields in form (including 'Service Start Time' and 'Service End Time' fields if applicable).
  12. Click 'Submit' button to file 'Claim Processing (UB-04)' form (or 'Claim Processing (UB-04) With Override' form).
Scenario 3: 'Fast Service Entry' - Verification Of Service Time Fields
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Service Times' must be enabled
  • CPT Code Definition where 'Require Service Time' is set to 'Yes' (via Avatar MSO 'CPT Code Definition' form)
  • Client record(s) valid for Service Entry/Claim Processing
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (or 'Fast Service Entry Submission' form).
  2. Enter/select value in 'Date Claims Received' and 'Close Batches' fields (if applicable).
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select client for service entry in 'Member Name or ID', field.
  6. Enter/Select value in 'Funding Source' field.
  7. Enter/select value in 'Provider' field.
  8. Enter/select 'Date of Service' field value.
  9. Enter/select 'Procedure Code' field value.
  10. If 'Require Service Time' is set to 'Yes' for CPT Code entered/selected in 'Procedure Code' field, ensure that 'Service Start Time' and 'Service End Time' fields are enabled and required in form.
  11. If 'Require Service Time' is set to 'No' for CPT Code entered/selected in 'Procedure Code' field (or no value is defined), ensure that 'Service Start Time' and 'Service End Time' fields are disabled (and not required in form).
  12. Enter/select values for all required/desired fields in form (including 'Service Start Time' and 'Service End Time' fields if applicable).
  13. Click 'Submit' button to file 'Fast Service Entry' form (or 'Fast Service Entry Submission' form).
Topics
• Claims Processing • CPT Code Definition • NX • Registry Settings • Revenue Code Definition
Update 34 Summary | Details
Approve/Pend/Deny Rules Definition
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • CPT Code Definition (PM)
  • CPT Code Definition (MSO)
  • Admission (Outpatient)
  • Diagnosis
  • Financial Eligibility
  • Revenue Code Definition (PM)
  • Revenue Code Definition (MSO)
  • Program Maintenance
  • Guarantors/Payors
  • Funding Source Registration
  • Plan Definition
  • Provider Fee Definition
  • MSO to Parent System Integration Mapping
  • Funding Source 837 Defaults
  • Approve/Pend/Deny Rules Definition
  • Claim Processing (CMS 1500)
  • Manual Batch Adjudication
  • Claim Processing (UB-04)
Scenario 1: Claim Processing - Verification of 'Claim Submitter ID Already Successfully Processed' Approve/Pend/Deny Rule
Specific Setup:
  • Two or more 837 Professional and/or 837 Institutional format inbound files for compilation and posting, including valid claims/services and where Claim Submitter ID' value (CLM-01) is repeated for two or more claims for same/single Contracting Provider
Steps
  1. Open Avatar MSO 'Approve/Pend/Deny Rules Definition' form.
  2. Set adjudication status value (approve, pend or deny) for 'Claim Submitter ID Already Successfully Processed' rule, and submit 'Approve/Pend/Deny Rules Definition' form.
  3. Load and compile/post 837 inbound file (via '837 Health Care Claim Professional' and/or '837 Health Care Claim Institutional' forms, or via import/export automatic file processing) where 'Claim Submitter ID' value (CLM-01) has already been used in a previously posted claim for the Contracting Provider (and is thus repeated for two or more claims with the current 837 inbound file). This claims processing rule will check against 'Claim Submitter ID' value for previously posted claims/services for same Contracting Provider regardless of approved/denied claim status.
  4. Adjudicate 837 inbound claims/services following posting (via 'Claims Processing...' and/or 'Manual Batch Adjudication' forms, or via automatic system adjudication process).
  5. Open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms.
  6. Navigate to 'Service Detail' section of form.
  7. Select service row and click 'Edit Selected Item'.
  8. For services in claims where 'Claim Submitter ID' value has not been used in any previously posted claim for the same Contracting Provider, ensure that 'Claim Status' field is set to 'Approved' (subject to all other applicable Approve/Pend/Deny Rules/conditions).
  9. For services in claims where 'Claim Submitter ID' value has already been used in a previously posted claim for the same Contracting Provider, ensure that 'Claim Status' field is set to status defined for the 'Claim Submitter ID Already Successfully Processed' Approve/Pend/Deny Rule.
  10. For services in claims where 'Claim Submitter ID' value has already been used in a previously posted claim for the same Contracting Provider, ensure that 'Explanation of Coverage' includes reason value 'Claim Submitter ID Already Successfully Processed'. (Example: "The service was denied for the following reason: Claim Submitter ID Already Successfully Processed")
Performing Provider Registration
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
Specific Setup:
  • A 'Performing Provider Registration' exists that has data filed for all required fields and includes a value in the optional field, 'Registration End Date'.
Steps
  1. Open 'Performing Provider Registration'.
  2. Select the 'Performing Provider Registration' from SETUP.
  3. Edit the value in the 'Registration End Date' field, noting the new value.
  4. Click [Submit].
  5. Click [Yes] on 'Pre-Display Confirmation' message.
  6. Click [Edit].
  7. Validate that the 'Registration End Date' field contains the new value.
  8. Delete the value in 'Registration End Date'
  9. Click [Submit].
  10. Click [No] on 'Pre-Display Confirmation' message.
  11. Open 'Performing Provider Registration'.
  12. Select the 'Performing Provider Registration' from SETUP.
  13. Click [Edit].
  14. Validate that the 'Registration End Date' field is blank.
  15. Enter the same value in 'Registration End Date' that was entered in step 3.
  16. Click [Submit].
  17. Click [Yes] on 'Pre-Display Confirmation' message.
  18. Click [Edit].
  19. Click [T] 'Registration End Date'.
  20. Click [Submit].
  21. 21. Click [Yes] on 'Pre-Display Confirmation' message.
  22. 22. Validate that the 'Registration End Date' is today’s date.
  23. 23. Close the form.
Topics
• Claims Processing • Performing Provider
Update 37 Summary | Details
Avatar MSO 'Create EOB' Form/Function
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Create EOB
  • Retro Claim Adjudication
Scenario 1: 'Create EOB' form - Verification of EOB Creation With 'Retro Claim Adjudication' Entries Included
Specific Setup:
  • One or more claims/services in 'Closed' status Claims Processing Batch(es), included on Voucher and not yet included on EOB
  • One or more Retro Claim Adjudication entries not yet included on an EOB (and where 'Withhold Payment' is filed as 'Yes')
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open 'Create EOB' form.
  2. Note - Acceptance testing may also be confirmed via Avatar MSO Claims Processing Automation EOB creation
  3. Select 'All' or 'Individual Providers' for EOB creation.
  4. Click 'Submit' button.
  5. Ensure EOB creation confirmation message is displayed on process completion.
  6. In EOB creation confirmation message, ensure that 'Total Amount of EOB(s) Created' value reflects/includes sum of all service 'Expected Disbursement' amounts and Retro Claim Adjudication entry/entries 'Take Back Amount' included in EOB(s) generated.
  7. In EOB creation confirmation message, ensure that 'Total Number of EOB(s) Created' value reflects total number of EOB(s) created.
  8. Open Crystal Reports or other SQL reporting tool.
  9. In Avatar MSO SQL table 'SYSTEM.table_eob', ensure that row(s) are present in table for all services and/or Retro Claim Adjudication entries included in EOB(s).
  10. In Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications', ensure that 'EOBID' value is updated to newly created EOB number for all Retro Claim Adjudication entries included in EOB(s).
Topics
• Create EOB