Approve/Pend/Deny Rules Definition
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Admission
- Admission (Outpatient)
- Approve/Pend/Deny Rules Definition
- Authorization Listing
- Batch Creation
- Claim Processing (CMS 1500)
- Claim Processing (UB-04)
- Close Batch
- Contracting Provider Registration
- CPT Code Definition (MSO)
- CPT Code Definition (PM)
- Diagnosis
- Financial Eligibility
- Funding Source 837 Defaults
- Funding Source Registration
- Guarantors/Payors
- Manual Batch Adjudication
- Member Specific Information
- MSO to Parent System Integration Mapping
- Plan Definition
- Program Maintenance
- Provider Fee Definition
- Registry Settings (PM)
- Revenue Code Definition (MSO)
- Revenue Code Definition (PM)
- Service Authorization
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
- Open Avatar MSO 'Approve/Pend/Deny Rules Definition' form.
- Set adjudication status value (approve, pend or deny) for 'Claim Submitter ID Already Successfully Processed' rule, and submit 'Approve/Pend/Deny Rules Definition' form.
- 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.
- Adjudicate 837 inbound claims/services following posting (via 'Claims Processing...' and/or 'Manual Batch Adjudication' forms, or via automatic system adjudication process).
- Open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms.
- Navigate to 'Service Detail' section of form.
- Select service row and click 'Edit Selected Item'.
- 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).
- 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.
- 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")
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Topics
• Claims Processing
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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
- Open 'Performing Provider Registration'.
- Select the 'Performing Provider Registration' from SETUP.
- Edit the value in the 'Registration End Date' field, noting the new value.
- Click [Submit].
- Click [Yes] on 'Pre-Display Confirmation' message.
- Click [Edit].
- Validate that the 'Registration End Date' field contains the new value.
- Delete the value in 'Registration End Date'
- Click [Submit].
- Click [No] on 'Pre-Display Confirmation' message.
- Open 'Performing Provider Registration'.
- Select the 'Performing Provider Registration' from SETUP.
- Click [Edit].
- Validate that the 'Registration End Date' field is blank.
- Enter the same value in 'Registration End Date' that was entered in step 3.
- Click [Submit].
- Click [Yes] on 'Pre-Display Confirmation' message.
- Click [Edit].
- Click [T] 'Registration End Date'.
- Click [Submit].
- 21. Click [Yes] on 'Pre-Display Confirmation' message.
- 22. Validate that the 'Registration End Date' is today’s date.
- 23. Close the form.
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Topics
• Performing Provider
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