Avatar MSO/Avatar PM 'Additional Claim Follow-Up' Filing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Client Ledger
- Create EOB
- Provider Fee Definition
- Registry Settings (PM)
- Retro Claim Adjudication
Scenario 1: 'Retro Claim Adjudication' - Verification of Claim Follow-Up Filing in Avatar PM/Cal-PM With Multiple/Partial 'Take Back Amount' Entries
Specific Setup:
- Avatar Cal-PM Registry Setting 'Claim Follow-Up' must be enabled
- Avatar Cal-PM Registry Setting 'Support Additional Claim Follow-Up Functionality' must be enabled
- Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (and override in use for service CPT/Revenue Code via 'Provider Fee Definition' form 'Fee Override In PM' section)
- One or more services in 'Closed' status Claim Processing batch(es) eligible for Retro Claim Adjudication entry, where services have also been pushed to Avatar Cal-PM parent system and included in Cal-PM 837 outbound bill/claim
Steps
- Open Avatar MSO 'Retro Claim Adjudication' form.
- Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field.
- Select 'Claim' and 'Date of Service/Procedure' values for Retro Claim Adjudication entry/update, selecting service which has been pushed to Avatar PM parent system and included in Cal-PM 837 outbound bill/claim.
- Enter value for 'Updated Approved Units' and calculate or directly update 'Updated Disbursement Amount' field to value less than 'Total Charge'/'Original Disbursement Amount' for service but greater than zero (so that Retro Claim Adjudication entry is partial and not full service takeback/Void entry).
- Allow system-calculation of updated values or directly enter value for 'Take Back Amount' - ensuring that 'Take Back Amount' is less than 'Total Charge'/'Original Disbursement Amount' for service but greater than zero (so that Retro Claim Adjudication entry is partial and not full service takeback/Void entry).
- Select value for 'Adjustment Code' field if not defaulted automatically.
- Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
- Open Avatar Cal-PM 'Client Ledger' form.
- Enter/select values for 'Client ID', 'Claim/Episode/All Episodes', 'From Date', 'To Date' and 'Ledger Type' values, and click 'Process' button to view Client Ledger information.
- For services originating in Avatar MSO and included in Cal-PM 837 outbound bill/claim - ensure that no Claim Follow-Up 'Void' entry is present for service(s) with partial takeback 'Retro Claim Adjudication' entry (as denoted by 'Claim Number' not including 'V' Void marker in Client Ledger information).
- Open Avatar Cal-PM 'Claim Follow-Up' form and select client.
- Ensure that no Claim Follow-Up entry is filed for partial takeback 'Retro Claim Adjudication' entry for service(s).
- Open Avatar MSO 'Create EOB' form.
- Enter/select values for 'All or Individual Providers', including Contracting Provider where partial takeback 'Retro Claim Adjudication' entry is present.
- Click 'Submit' to file form/create EOB, allowing second/subsequent Retro Claim Adjudication entry for same claim/service(s).
- Open Avatar MSO 'Retro Claim Adjudication' form.
- Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field.
- Select 'Claim' and 'Date of Service/Procedure' values for Retro Claim Adjudication entry/update, selecting service which has been pushed to Avatar PM parent system and included in Cal-PM 837 outbound bill/claim, where previous Retro Claim Adjudication entry with partial takeback exists.
- Enter value for 'Updated Approved Units' field and calculate or directly update 'Updated Disbursement Amount' field to zero (so that Retro Claim Adjudication second/subsequent entry is full service takeback/Void entry in conjunction with previously entered 'Take Back Amount' values).
- Allow system-calculation of updated values or directly enter value for 'Take Back Amount' - ensuring that 'Take Back Amount' is equal to the difference between the previous Retro Claim Adjudication 'Take Back Amount' entry/entries and 'Total Charge'/'Original Disbursement Amount' for the service (so that Retro Claim Adjudication second/subsequent entry is full service takeback/Void entry in conjunction with previously entered 'Take Back Amount' values).
- Select value for 'Adjustment Code' field if not defaulted automatically.
- Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
- Open Avatar Cal-PM 'Client Ledger' form.
- Enter/select values for 'Client ID', 'Claim/Episode/All Episodes', 'From Date', 'To Date' and 'Ledger Type' values, and click 'Process' button to view Client Ledger information.
- For services originating in Avatar MSO and included in Cal-PM 837 outbound bill/claim - ensure that Claim Follow-Up 'Void' entry is present for service(s) with multiple partial takeback 'Retro Claim Adjudication' entries totaling to a full takeback/'Void' entry in Avatar MSO (as denoted by 'Claim Number' including 'V' Void marker in Client Ledger information).
- Note - The Avatar MSO-generated Claim Follow-Up 'Void' will be in 'Pended' status, and 'V' Void marker not yet present in Client Ledger information if 835 Health Care Claim Remittance/Advice payment/adjustment information has not yet been posted for original Cal-PM Electronic Billing 837 claim(s); this will be updated following 835 payment/adjustment posting for original 837 claim(s).
- Open Avatar Cal-PM 'Claim Follow-Up' form and select client.
- Select 'Edit' in 'Add, Edit or Delete Claim Follow-Up' field, and select Claim Follow Up Entry for review.
- Ensure that Claim Follow-Up entry exists for service(s) with multiple partial takeback 'Retro Claim Adjudication' entries totaling to a full takeback/'Void' entry in Avatar MSO.
- Note - The Avatar MSO-generated Claim Follow-Up entry will be in 'Pended' status if 835 Health Care Claim Remittance/Advice payment/adjustment information has not yet been posted for original Cal-PM Electronic Billing 837 claim(s); this will be updated following 835 payment/adjustment posting for original 837 claim(s).
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Topics
• NX
• Retro Claim Adjudication
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