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Avatar MSO 2022 Quarterly Release 2022.02 Acceptance Tests

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Update 2 Summary | Details
Site Specific Section Modeling - Fast Service Entry Submission
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Guarantors/Payors
  • Admission (Outpatient)
  • Dynamic Form - Pre-Display Confirmation
  • CPT Code Definition (PM)
  • CPT Code Definition (MSO)
  • Revenue Code Definition (PM)
  • Revenue Code Definition (MSO)
  • Service Codes
  • Plan Definition
  • Funding Source Registration
  • Applying Contracting Provider
  • Provider Fee Definition
  • MSO to Parent System Integration Mapping
  • Dynamic Form - Site Specific Section Modeling (CWS)
  • Site Specific Section Modeling (MSO)
Scenario 1: 'Claim Processing...' forms and functions - Verification of 'Explanation Of Coverage' value for 'Pended' Service Authorization, and verifying new batch not created when batch is closed
Specific Setup:
  • Client record with Service Authorization(s) where 'Current Authorization Status' value is 'Pending'
  • One or more claim(s)/service(s) for adjudication where 'Pending' status Service Authorization is selected/associated to service
Steps
  1. Open Avatar MSO 'Claim Processing...' form ('Claim Processing (CMS 1500)', 'Claim Processing (UB-04)' and/or 'Fast Service Entry' forms).
  2. Select claims processing batch for service entry/edit.
  3. Open existing claim or create new claim for service entry/edit.
  4. Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
  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', 'Procedure Code', 'Total Charge' and 'Service Units' field values.
  8. Click 'Display Valid Authorizations' button and select Service Authorization (or directly enter value in 'Authorization Number' field).
  9. In case where 'Current Authorization Status' value is 'Pending' for selected/associated Service Authorization record - ensure that 'Claim Status' value is set to 'Pending' for service.
  10. In case where 'Current Authorization Status' value is 'Pending' for selected/associated Service Authorization record - ensure that 'Explanation Of Coverage' field for service includes value 'The service was pended for the following reason: Authorization is pending'.
  11. Click [Enter Third Party Adjudication Data].
  12. Create a new row with desired data, and if desired click [View] and create a new row with desired data. Save the rows.
  13. Click [Submit].
  14. Close the batch and validate that a new pended batch is created.
  15. Repeat steps 1-12 and validate that the ‘Third Party Adjudication Data’ was copied forward.
  16. Click [Submit].
  17. Close the batch and validate that a new pended batch is created.
  18. Repeat steps 1-12 and validate that the ‘Third Party Adjudication Data’ was copied forward.
Scenario 2: Avatar MSO 'Site Specific Section Modeling' - 'Fast Service Entry Submission' - opening prompt section.
Specific Setup:
  • Site Specific Section Modeling for MSO:
  • Select the ‘MSOBAT185SUBMISSION (Fast Service Entry Submission) Fast Service Detail’ item in the dropdown list.
  • Click [OK].
  • Select ‘Prompt Definition’ section.
  • If desired, add a new prompt and customize the label or customize the label of an existing prompt.
  • Click [Submit].
  • Refresh the forms.
Steps
  1. Open ‘Fast Service Entry’.
  2. Select the ‘Fast Service Detail’ section.
  3. Validate that the prompt that was added or changed exists on the form.
  4. Close the form.
  5. Open ‘Site Specific Section Modeling’ for MSO.
  6. Select the ‘MSOBAT185OVERRIDE (Fast Service Entry) Fast Service Detail’ item in the dropdown list.
  7. Click [OK].
  8. Select ‘Prompt Definition’ section.
  9. Validate that the prompt added or changed in Setup displays in the table.
  10. Select the prompt and click [Delete Selected Item].
  11. Click [Yes] on the ‘Confirm’ message.
  12. Click [Submit].
  13. Refresh the forms.
  14. Open ‘Fast Service Entry’.
  15. Select the ‘Fast Service Detail’ section.
  16. Validate that the prompt does not exist.
Claim Processing - Third Party Adjudication Data
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Guarantors/Payors
  • Admission (Outpatient)
  • Dynamic Form - Pre-Display Confirmation
  • CPT Code Definition (PM)
  • CPT Code Definition (MSO)
  • Revenue Code Definition (PM)
  • Revenue Code Definition (MSO)
  • Service Codes
  • Plan Definition
  • Funding Source Registration
  • Applying Contracting Provider
  • Provider Fee Definition
  • MSO to Parent System Integration Mapping
  • Dynamic Form - Site Specific Section Modeling (CWS)
  • Site Specific Section Modeling (MSO)
Scenario 1: 'Claim Processing...' forms and functions - Verification of 'Explanation Of Coverage' value for 'Pended' Service Authorization, and verifying new batch not created when batch is closed
Specific Setup:
  • Client record with Service Authorization(s) where 'Current Authorization Status' value is 'Pending'
  • One or more claim(s)/service(s) for adjudication where 'Pending' status Service Authorization is selected/associated to service
Steps
  1. Open Avatar MSO 'Claim Processing...' form ('Claim Processing (CMS 1500)', 'Claim Processing (UB-04)' and/or 'Fast Service Entry' forms).
  2. Select claims processing batch for service entry/edit.
  3. Open existing claim or create new claim for service entry/edit.
  4. Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
  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', 'Procedure Code', 'Total Charge' and 'Service Units' field values.
  8. Click 'Display Valid Authorizations' button and select Service Authorization (or directly enter value in 'Authorization Number' field).
  9. In case where 'Current Authorization Status' value is 'Pending' for selected/associated Service Authorization record - ensure that 'Claim Status' value is set to 'Pending' for service.
  10. In case where 'Current Authorization Status' value is 'Pending' for selected/associated Service Authorization record - ensure that 'Explanation Of Coverage' field for service includes value 'The service was pended for the following reason: Authorization is pending'.
  11. Click [Enter Third Party Adjudication Data].
  12. Create a new row with desired data, and if desired click [View] and create a new row with desired data. Save the rows.
  13. Click [Submit].
  14. Close the batch and validate that a new pended batch is created.
  15. Repeat steps 1-12 and validate that the ‘Third Party Adjudication Data’ was copied forward.
  16. Click [Submit].
  17. Close the batch and validate that a new pended batch is created.
  18. Repeat steps 1-12 and validate that the ‘Third Party Adjudication Data’ was copied forward.
Scenario 2: Avatar MSO 'Site Specific Section Modeling' - 'Fast Service Entry Submission' - opening prompt section.
Specific Setup:
  • Site Specific Section Modeling for MSO:
  • Select the ‘MSOBAT185SUBMISSION (Fast Service Entry Submission) Fast Service Detail’ item in the dropdown list.
  • Click [OK].
  • Select ‘Prompt Definition’ section.
  • If desired, add a new prompt and customize the label or customize the label of an existing prompt.
  • Click [Submit].
  • Refresh the forms.
Steps
  1. Open ‘Fast Service Entry’.
  2. Select the ‘Fast Service Detail’ section.
  3. Validate that the prompt that was added or changed exists on the form.
  4. Close the form.
  5. Open ‘Site Specific Section Modeling’ for MSO.
  6. Select the ‘MSOBAT185OVERRIDE (Fast Service Entry) Fast Service Detail’ item in the dropdown list.
  7. Click [OK].
  8. Select ‘Prompt Definition’ section.
  9. Validate that the prompt added or changed in Setup displays in the table.
  10. Select the prompt and click [Delete Selected Item].
  11. Click [Yes] on the ‘Confirm’ message.
  12. Click [Submit].
  13. Refresh the forms.
  14. Open ‘Fast Service Entry’.
  15. Select the ‘Fast Service Detail’ section.
  16. Validate that the prompt does not exist.
Topics
• Claims Processing • Service Authorizations • Site Specific Section Modeling • NX
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 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
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
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 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 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 10 Summary | Details
'Provider File Attach' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Provider File Attach
Scenario 1: 'Provider File Attach' - Form Verification
Specific Setup:
  • Document Management Configuration must be defined for Cache Server or Perceptive (via Avatar PM / RADplus Utilities 'Document Management Defaults' form)
  • Dictionary Codes may optionally be defined for 'Other Tabled Files' Data Element '(70007) Document Type' (via Avatar MSO 'Dictionary Update' form)
  • One or more .PDF (Adobe Portable Document Format) and/or .TIF (Tagged Image File Format) files for Provider File Attach upload/storage
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO 'Provider File Attach' form (under 'Avatar MSO / Provider Management' menu).
  2. Enter/select 'Member ID' value.
  3. Enter/select 'Provider' value.
  4. In 'File Type' field, ensure the following selections are available:
  5. 'Authorization' (will link File Attachment to a specific Avatar MSO Service Authorization record for selected Provider)
  6. 'Provider' (will link File Attachment to selected Provider)
  7. 'Other' (will link File Attachment to selected Provider)
  8. Select 'File Type' value.
  9. If 'Authorization' is selected in 'File Type' field, ensure that 'Authorization' selection field is enabled, and includes only Avatar MSO Service Authorization records for selected Provider; select 'Authorization' field if applicable.
  10. Select 'Document Type' value (optional field).
  11. Enter 'Comments' value if desired (optional field).
  12. Click 'Upload File' button, and select file for Provider Attachment upload/storage.
  13. On completion of File Attachment upload, ensure 'File Name' field is populated with uploaded file name.
  14. Click 'Store File' field to store File Attachment in Avatar MSO; ensure user is presented with confirmation dialog noting 'File successfully created'.
  15. Click 'OK' button to return to 'Provider File Attach' form.
  16. Select 'File Type' value for previously uploaded/stored File Attachment.
  17. Ensure uploaded/stored File Attachment files are listed/available for selection in the 'Existing Files' field; select file in 'Existing Files' field.
  18. Ensure that 'Comment History' field displays entered/updated 'Comments' field entries for selected file (with username and date/timestamp associated to each 'Comments' entry).
  19. Example:
  20. "Comment 1 AVATAR USERNAME 1 2022-04-21 04:19PM"
  21. Enter additional/new 'Comments' field data for selected File Attachment.
  22. Click 'Update Comments' button to store additional/new 'Comments' field data for selected File Attachment; ensure user is presented with confirmation dialog noting 'Comments Successfully updated'.
  23. Click 'OK' button to return to 'Provider File Attach' form.
  24. Select 'File Type' value for previously uploaded/stored File Attachment.
  25. Select uploaded/stored File Attachment in 'Existing Files' field.
  26. Ensure that 'Comment History' field displays all previously entered/updated 'Comments' field entries for selected file (with username and date/timestamp associated to each 'Comments' entry).
  27. Example:
  28. "Comment 2 AVATAR USERNAME 2 2022-04-22 01:35PM / Comment 1 AVATAR USERNAME 1 2022-04-21 04:19PM"
  29. Select 'File Type' value.
  30. Click 'Upload File' button, and select file for Provider Attachment upload/storage - selecting file with same name as previously uploaded/stored File Attachment.
  31. If file with same name as previously uploaded/stored File Attachment (for same Member ID/client) is selected, ensure user is presented with error dialog noting 'File already exists on the server' on clicking 'Store File' button (and File Attachment is disallowed).
  32. Select 'File Type' value for previously uploaded/stored File Attachment.
  33. Select uploaded/stored File Attachment file in 'Existing Files' field.
  34. Click 'Delete File' button to delete File Attachment.
  35. Ensure user is presented with Delete File confirmation dialog noting 'Are you sure you want to delete this file?'; click 'Yes' button to confirm file deletion.
  36. Ensure user is presented with Delete File confirmation dialog noting 'File deleted successfully'; click 'OK' button to return to 'Provider File Attach' form.
  37. Select 'File Type' value for previously uploaded/stored File Attachment.
  38. Ensure deleted File Attachment files are not listed/not available for selection in the 'Existing Files' field.
  39. Open Crystal Reports or other SQL reporting tool.
  40. In Avatar MSO SQL table 'SYSTEM.file_attach_object', ensure that all uploaded/stored File Attachment files are present in SQL table data (one row per File Attachment).
  41. In Avatar MSO SQL table 'SYSTEM.file_attach_comments', ensure that all entered/updated 'Comments' field entries for File Attachment are present in SQL table data (one row per 'Comments' entry for File Attachment).
Avatar MSO 'Provider File Attach' Widget
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • View Definition
  • NX View Definition
  • Provider File Attach
  • Provider File Attach Widget
Scenario 1: 'Provider File Attach' Widget - Widget Display Verification
Specific Setup:
  • Document Management Configuration must be defined for Cache Server or Perceptive (via Avatar PM / RADplus Utilities 'Document Management Defaults' form)
  • 'Provider File Attach' Widget must be assigned to Chart View Definition/Home View Definition/Client Dashboard View assigned to user (via 'View Definition' form / 'NX View Definition' form)
  • One or more .PDF (Adobe Portable Document Format) and/or .TIF (Tagged Image File Format) files uploaded/stored via Avatar MSO 'Provider File Attach' form
Steps
  1. Open 'View Definition' form (under 'Avatar PM / RADplus Utilities / Widget Management' menu).
  2. Click 'Select View' button and select View Definition for update (or select 'Add New View' for new View Definition entry).
  3. Click 'Launch View Designer' button.
  4. In 'View Definition' form View Designer, ensure that Avatar MSO 'Provider File Attach' Widget is available for assignment (under 'Client' category).
  5. Select/add Avatar MSO 'Provider File Attach' Widget to View; click 'Submit' button to save View Designer layout, and click 'Submit' button to file 'View Definition' form.
  6. Navigate/select Home View, Chart View or Client Dashboard View where Avatar MSO 'Provider File Attach' Widget is assigned/present.
  7. Ensure that the 'Provider File Attach' Widget displays all uploaded/stored File Attachment files for selected/currently active Member ID/Client (one row in Widget display per File Attachment).
  8. Ensure that the 'Provider File Attach' Widget includes the following columns/information for each File Attachment row for selected/currently active Member ID/Client:
  9. 'View' button
  10. This button will open the selected .PDF or .TIF File Attachment file in the Console Widget Viewer
  11. 'Provider' display
  12. 'Document Name' display
  13. 'Date' display
  14. 'Authorization Number' display
  15. If applicable/value present, otherwise blank
  16. 'Document Type' display
  17. If applicable/value present, otherwise 'No Entry'
Scenario 2: 'Provider File Attach' Widget - Verification of File Attachment Display in 'Console Widget Viewer'
Specific Setup:
  • Avatar PM/RADplus Registry Setting 'Enable Console Widgets/Views' must be enabled
  • Document Management Configuration must be defined for Cache Server or Perceptive (via Avatar PM / RADplus Utilities 'Document Management Defaults' form)
  • Avatar MSO 'Provider File Attach' Widget must be assigned to Chart View Definition/Home View Definition/Client Dashboard View assigned to user (via 'View Definition' form / 'NX View Definition' form)
  • Avatar NX/myAvatar 'Console Widget Viewer' must be assigned to Chart View Definition/Home View Definition/Client Dashboard View assigned to user (via 'View Definition' form / 'NX View Definition' form)
  • One or more .PDF (Adobe Portable Document Format) and/or .TIF (Tagged Image File Format) files uploaded/stored via Avatar MSO 'Provider File Attach' form
Steps
  1. Navigate/select Home View, Chart View or Client Dashboard View where Avatar MSO 'Provider File Attach' Widget and Avatar NX/myAvatar 'Console Widget Viewer' are assigned/present.
  2. Ensure that the 'Provider File Attach' Widget displays all uploaded/stored File Attachment files for selected/currently active Member ID/Client (one row in Widget display per File Attachment).
  3. Click 'View' button in 'Provider File Attach' Widget to view selected File Attachment.
  4. Ensure that selected .PDF or .TIF File Attachment image is opened for display in Avatar NX/myAvatar 'Console Widget Viewer'.
  5. Ensure multiple File Attachments may be opened/displayed in Avatar NX/myAvatar 'Console Widget Viewer' from 'Provider File Attach' Widget simultaneously.
  6. Ensure File Attachment images may be closed within Avatar NX/myAvatar 'Console Widget Viewer' (by closing individual files/tabs within viewer, or use of the 'Close All' button).
Topics
• NX • Provider File Attach • Widgets • Console Widget
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 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
Update 13 Summary | Details
Avatar MSO 'Claim Acknowledgement (277CA) File' Form/Function
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Claim Acknowledgement (277CA) File
  • 837 Health Care Claim Institutional
Scenario 1: 'Claim Acknowledgement (277CA) File' - Verification of Claim Acknowledgement File Creation
Specific Setup:
  • File path for 277CA Claim Acknowledgement file creation must be defined in the 'Output Directory' field for system (via Avatar MSO 'Set System Defaults' or 'Import/Export File Configuration' form)
  • Avatar MSO Claims Processing Batch(es) may optionally be set to automatically close following 837 posting (via Avatar 'Claim Processing Automation' form)
  • 277CA Claim Acknowledgment file may optionally be enabled for automatic generation (via Avatar MSO 'Import/Export File Configuration' form)
  • 837 Professional and/or Institutional format inbound file(s) for compilation/posting, including one or more 'Pending' Claim Status service(s)
Steps
  1. Using Avatar MSO '837 Health Care Claim Professional' and/or '837 Health Care Claim Institutional' forms (or via Avatar MSO automated 837 file processing), load/compile/post inbound 837 file(s) containing one or more valid claim(s) where Claim Status for one or more service(s) is 'Pending'.
  2. Avatar MSO Claims Processing batch(es) created via inbound 837 file posting may be 'Open' or 'Closed' status, including batches closed automatically via 'Claim Processing Automation' functionality.
  3. Open the Avatar MSO 'Claim Acknowledgement (277CA) File' form.
  4. 277CA file generation/content review may also be confirmed directly in system output directory where automatic 277CA file generation is enabled.
  5. Select 'Create File On Server' in 'Options' field.
  6. Select 'Submission Type' field value ('Institutional' or 'Professional').
  7. Select 837 file for Claim Acknowledgement (277CA) file creation.
  8. Click 'Process' button.
  9. Ensure that for selected 837 file, Claim Acknowledgement (277CA) file is created on server in defined directory.
  10. This may be confirmed via the 'Claim Acknowledgement (277CA) File' form 'Run Report' or 'Dump File' options, and/or by reviewing files in 277CA output directory.
  11. Select 'Dump File' in 'Options' field.
  12. Select 'Submission Type' field value ('Institutional' or 'Professional').
  13. Select 837 file for Claim Acknowledgement (277CA) file review.
  14. Click 'Process' button.
  15. In 277CA Claim Acknowledgement file(s) for successfully posted 837 Professional and/or Institutional inbound claims including one or more 'Pending' Claim Status service(s), ensure that claim/service(s) is/are reported with 'Accepted' status (including case where 837 Claims Processing batch containing 'Pending' status service is automatically closed following 837 posting).
  16. Examples:
  17. 'STC*A2:20**WQ*180~'
  18. 'STC*A2:20*20220516*WQ*60~'
  19. 277CA file content review may also be confirmed directly in system output directory by opening/reviewing file(s).
Topics
• 837 Health Care Claim Professional • Claims Processing • 837 Health Care Claim Institutional
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