'Claim PreAdjudication' Web Service
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Claim Pre-Adjudication Web Service
Scenario 1: 'Claim Pre-Adjudication' Web Service - Receipt and processing of claim/service data from ProviderConnect
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 Pre-Adjudication' web service)
- 'Crystal Reports' or other SQL reporting tool
Steps
- Enter one or more services via Netsmart ProviderConnect 'Treatment' service entry.
- Navigate to ProviderConnect 'Billing' menu.
- Click 'Generate Bill' button for selected criteria.
- Click 'Click 'Submit Bill for Pre-adjudication' button for ProviderConnect billing transaction (or via other application utilizing the Avatar MSO 'Claim Pre-Adjudication' web service).
- Within 'Unsubmitted Bills' section of ProviderConnect 'Billing' menu, navigate to bill created above which was submitted for Pre-Adjudication.
- Click 'View Pre-adjudication Results' button for unsubmitted bill.
- For all services in bill submitted for Pre-Adjudication but not yet processed by Avatar MSO, ensure 'Status' value is 'Queued'.
- 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.
- Click the 'Refresh Bill Pre-adjudication Results' button.
- 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).)
- 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.)
- Open 'Crystal Reports' or other SQL reporting tool.
- In Avatar MSO SQL table 'SYSTEM.claims_pre_adj table' - ensure new single row is present for each service submitted/processed by Claim Pre-Adjudication web service/background process.
- In Avatar MSO SQL table 'SYSTEM.claims_pre_adj table' - for each service submitted/processed, confirm 'Queued', 'Passed Edit' or 'Failed Edit' status in field 'status' (value 'Q', '1' or '0', respectively).
- In Avatar MSO SQL table 'SYSTEM.claims_pre_adj table' - for each service submitted/processed with 'Failed Edit' status, confirm 'Pre-Adjudication Edit Failed Reason' values in field 'pre_adj_edit_failed_reason'.
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Topics
• Claims Processing
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