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Avatar MSO 2023 Monthly Release 2023.00.00 Acceptance Tests

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Update 1 Summary | Details
Avatar MSO 2023 is Installed
Scenario 1: Validate Upgrading Avatar MSO 2022 to 2023 is successful when 2022.04.00 is loaded
Specific Setup:
  • Latest Monthly Release is installed.
Steps
  1. Open the "Product Updates" form.
  2. Select the appropriate [Namespace] from the Application dropdown list
  3. Click [Select Update/Customization Pack].
  4. Browse to the location for the updates and select the Update 1.
  5. Click [OK] on the "File Upload Complete" window.
  6. Click [Review Update/Customization Pack Contents].
  7. Verify Update 1 is included.
  8. Click [Install Update/Customization Pack].
  9. Click [OK] when the install completes.
  10. Click [Close Form].
Topics
• Upgrade
2022 Update 30 Summary | Details
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:
  • Registry Settings (PM)
  • Provider Fee Definition
  • Create EOB
  • Client Ledger
  • 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
  1. Open Avatar MSO 'Retro Claim Adjudication' form.
  2. Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field.
  3. 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.
  4. 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).
  5. 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).
  6. Select value for 'Adjustment Code' field if not defaulted automatically.
  7. Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
  8. Open Avatar Cal-PM 'Client Ledger' form.
  9. 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.
  10. 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).
  11. Open Avatar Cal-PM 'Claim Follow-Up' form and select client.
  12. Ensure that no Claim Follow-Up entry is filed for partial takeback 'Retro Claim Adjudication' entry for service(s).
  13. Open Avatar MSO 'Create EOB' form.
  14. Enter/select values for 'All or Individual Providers', including Contracting Provider where partial takeback 'Retro Claim Adjudication' entry is present.
  15. Click 'Submit' to file form/create EOB, allowing second/subsequent Retro Claim Adjudication entry for same claim/service(s).
  16. Open Avatar MSO 'Retro Claim Adjudication' form.
  17. Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field.
  18. 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.
  19. 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).
  20. 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).
  21. Select value for 'Adjustment Code' field if not defaulted automatically.
  22. Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
  23. Open Avatar Cal-PM 'Client Ledger' form.
  24. 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.
  25. 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).
  26. 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).
  27. Open Avatar Cal-PM 'Claim Follow-Up' form and select client.
  28. Select 'Edit' in 'Add, Edit or Delete Claim Follow-Up' field, and select Claim Follow Up Entry for review.
  29. 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.
  30. 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).
Topics
• Retro Claim Adjudication • NX
2022 Update 31 Summary | Details
Avatar MSO Automated 837 Health Care Claim Processing
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 - Verification of Duplicate 837 Inbound File Handling
Specific Setup:
  • Avatar MSO Automated 837 Health Care Claim Processing must be enabled and configured for system (via 'Import/Export File Configuration' form)
  • Inbound 837 Professional and/or Institutional format files for automated processing
Steps
  1. Place 837 Professional and/or Institutional inbound file(s) in 'Processing' directories for Avatar MSO Automated inbound 837 Health Care Claim processing (as defined via 'Import/Export File Configuration' form).
  2. Ensure Avatar MSO Automated inbound process for 837 Professional and Institutional files loads/compiles/posts each 837 inbound file in 'Processing' directories (according to behavior defined via 'Import/Export File Configuration' form).
  3. Ensure that inbound 837 automated processing completes for valid 837 inbound files placed in 'Processing' directories, and that valid files are correctly moved to 'Processed' directories.
  4. Place one or more 837 Professional and/or Institutional inbound file(s) with same/duplicate file name in 'Processing' directories for Avatar MSO Automated inbound 837 Health Care Claim processing
  5. Ensure Avatar MSO Automated inbound process for 837 Professional and Institutional files does not compile/post inbound 837 file(s) with same/duplicate file name as previously processed file; ensure that file extension is changed to .INVALID in 'Processing' directory.
  6. Ensure that in 'Error' file path directory, new error is recorded for duplicate/already processed files, noting '(Date/Time) - (File Path/Name) - The file '(File Path/Name)' has already been previously processed.'
  7. Example:
  8. '12/02/2022 11:51:13 - E:\INBOUND\AVPM_AUTOPROF\837InboundProf_AVMSO_DUPLICATECHECK.txt - The file 'E:\INBOUND\AVPM_AUTOPROF\837InboundProf_AVMSO_DUPLICATECHECK.txt' has already been previously processed.'
  9. Open Avatar MSO 'Import/Export File Configuration' form.
  10. Enter new value for 837 Professional 'Process File Path' and/or 837 Institutional 'Process File Path' configuration fields.
  11. Click 'Submit' button to file updated 'Import/Export File Configuration' values.
  12. Place one or more 837 Professional and/or Institutional inbound file(s) with same/duplicate file name in updated 'Processing' directories for Avatar MSO Automated inbound 837 Health Care Claim processing
  13. Ensure Avatar MSO Automated inbound process for 837 Professional and Institutional files does not compile/post inbound 837 file(s) with same/duplicate file name as previously processed file regardless of file path; ensure that file extension is changed to .INVALID in 'Processing' directory.
  14. Ensure that in 'Error' file path directory, new error is recorded for duplicate/already processed files, noting '(Date/Time) - (File Path/Name) - The file '(File Path/Name)' has already been previously processed.'
  15. Example:
  16. '12/02/2022 11:51:13 - E:\INBOUND\AVPM_AUTOPROF\NEW_PATH\837InboundProf_AVMSO_DUPLICATECHECK.txt - The file 'E:\INBOUND\AVPM_AUTOPROF\NEW_PATH\837InboundProf_AVMSO_DUPLICATECHECK.txt' has already been previously processed.'
'837 Health Care Claim Institutional' Invalid Data Handling
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Institutional
  • 837 Health Care Claim Institutional - Error Report
  • 837 Health Care Claim Institutional - Compile Report
Scenario 1: '837 Health Care Claim Institutional' - Validation of 2300 DTP Admission Date Format
Specific Setup:
  • 837 Health Care Claim Institutional file with one or more claims containing invalid 2300 DTP Admission Date value
  • Example: DTP*435*DT*2022101~
Steps
  1. Open '837 Health Care Claim Institutional' form.
  2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
  3. Select 'Load File' in the 'Options' field.
  4. Enter file path for inbound 837 Institutional format file and click 'Process' button.
  5. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
  6. Click 'Process' button.
  7. In 837 Institutional Compile Report - in case where one or more claim(s) include an invalid 2300 DTP Admission Date value, ensure that claim/service(s) are not successfully compiled (and are not included in 837 compile report).
  8. Select 'Run Error Report' in the 'Options' field, and select compiled 837 Institutional file.
  9. In 837 Institutional Error Report - in case where one or more claim(s) include an invalid 2300 DTP Admission Date value, ensure that claim is included in 837 error report with Error Type 'Critical Error' and Error Message 'Invalid admission date for claim.'
  10. Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
  11. Click 'Process' button.
  12. In 837 Institutional Post Report - in case where one or more claim(s) include an invalid 2300 DTP Admission Date value, ensure that claim/service(s) are not successfully posted (and are not included in 837 post report).
Avatar MSO Background Task Processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • View Definition
  • NX View Definition
  • 837 Health Care Claim Professional Automated Processing
  • 837 Health Care Claim Institutional Automated Processing
  • Claim Processing Automation
  • Claim Pre-Adjudication Web Service
Scenario 1: Automated 837 Professional/Institutional Process Status Widgets - Verification of Widget Data Display
Specific Setup:
  • Avatar MSO Automated 837 Health Care Claim Processing must be enabled and configured for system (via 'Import/Export File Configuration' form)
  • Avatar MSO Automated 837 Health Care Claim Processing may optionally be configured to automatically close batch(es) after 837 posting, create Vouchers and/or create EOBs (via 'Claim Processing Automation' form)
  • 'Automated MSO 837 Professional Process Status' and/or 'Automated MSO 837 Institutional Process Status' Widget must be assigned to user Home/myDay/Dashboard view (via RADplus 'View Definition'/'NX View Definition' form)
  • Inbound 837 Professional and/or Institutional format files for automated processing
Steps
  1. Place multiple 837 Professional and/or Institutional inbound files in 'Processing' directories for Avatar MSO Automated inbound 837 Health Care Claim processing (as defined via 'Import/Export File Configuration' form).
  2. Refresh the 'Automated MSO 837 Professional Process Status' and/or 'Automated MSO 837 Institutional Process Status' Widget within user's Home View/myDay View/Dashboard View.
  3. Ensure that 'Automated MSO 837 Professional Process Status' / 'Automated MSO 837 Institutional Process Status' Widgets display current/correct information for inbound 837 files processing/to be processed in the 'Status' and 'File Name' widget columns.
  4. Ensure Automated 837 file process loads/compiles/posts each 837 inbound file in 'Processing' directories as expected (according to behavior defined via 'Import/Export File Configuration' form).
  5. During/following additional Avatar MSO Automated inbound 837 file processing actions, refresh the 'Automated MSO 837 Professional Process Status' and/or 'Automated MSO 837 Professional Process Status' Widget within user's Home View/myDay View/Dashboard View, ensuring that display is updated with current/correct information for inbound 837 files processing/to be processed in the 'Status' and 'File Name' widget columns.
Scenario 2: Automated 837 Inbound Processing/Claim Processing Automation - Verification of 837 Processing
Specific Setup:
  • Avatar MSO Automated 837 Health Care Claim Processing must be enabled and configured for system (via 'Import/Export File Configuration' form)
  • Avatar MSO Automated 837 Health Care Claim Processing 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 Avatar MSO Automated inbound 837 Health Care Claim processing (as defined via 'Import/Export File Configuration' form).
  2. Ensure Avatar MSO Automated inbound process for 837 Professional and Institutional files loads/compiles/posts each 837 inbound file in 'Processing' directories (according to behavior defined via 'Import/Export File Configuration' form).
  3. Ensure for all Claims Processing batches created via inbound 837 automated processing are closed automatically if configured (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.
Scenario 3: 'Claim Pre-Adjudication' Web Service - Receipt and processing of claim/service data from ProviderConnect
Specific Setup:
  1. Client record eligible for Claim/Service entry in Avatar MSO and Netsmart ProviderConnect
  2. Netsmart ProviderConnect (or other application utilizing the Avatar MSO 'Claim Pre-Adjudication' web service)
  3. 'Crystal Reports' or other SQL reporting tool
Steps
  1. Enter one or more services via Netsmart ProviderConnect 'Treatment' service entry.
  2. Navigate to ProviderConnect 'Billing' menu.
  3. Click 'Generate Bill' button for selected criteria.
  4. 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).
  5. Within 'Unsubmitted Bills' section of ProviderConnect 'Billing' menu, navigate to bill created above which was submitted for Pre-Adjudication.
  6. Click 'View Pre-adjudication Results' button for unsubmitted bill.
  7. For all services in bill submitted for Pre-Adjudication but not yet processed by Avatar MSO, ensure 'Status' value is 'Queued'.
  8. 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.
  9. Click the 'Refresh Bill Pre-adjudication Results' button.
  10. 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).)
  11. 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.)
  12. Open 'Crystal Reports' or other SQL reporting tool.
  13. 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.
  14. 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).
  15. 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'.
Topics
• 837 Health Care Claim Professional • Claims Processing • 837 Health Care Claim Institutional • Widgets
2022 Update 38 Summary | Details
Avatar MSO 'Service Authorization' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Registry Settings (PM)
  • Procedure Code Group Definition
  • Provider Fee Definition
Scenario 1: 'Service Authorization' - Verification of 'Restrict Code Authorized By Provider' Registry Setting
Specific Setup:
  • Avatar MSO Registry Setting 'Restrict Code Authorized By Provider' must be enabled
  • One or more Procedure Code Group(s) including CPT Codes must be defined (via Avatar MSO 'Procedure Code Group Definition' form)
  • Provider Fee Definition(s) must be defined by Procedure Code Group for Contracting Provider (via Avatar MSO 'Provider Fee Definition' form)
Steps
  1. Open Avatar MSO 'Service Authorization' form.
  2. Select Client ID for 'Service Authorization' entry.
  3. Click 'Add' button in 'Service Authorization' form pre-display to enter a new record, or select existing row/record and click 'Edit' button to view/update existing record.
  4. Enter/select values for 'Funding Source Authorization Is For', 'Benefit Plan', 'Provider To Be Authorized', 'Begin Date Of Authorization', 'End Date Of Authorization' and 'Current Authorization Status' fields.
  5. Select 'Individual' in the 'Authorization Grouping Or Individual Authorizations' field.
  6. Select 'CPT Code' in the 'Procedure Code Type' field.
  7. Enter search term for CPT Code in 'Code Authorized' field.
  8. In 'Code Authorized' field search results - ensure that only CPT Codes where Provider Fee Definition for selected 'Provider To Be Authorized' are included/available for selection, including CPT Codes where applicable Provider Fee Definition is defined by Procedure Code Group for Contracting Provider.
  9. In 'Code Authorized' field search results - ensure that CPT Codes where no Provider Fee Definition exists for selected 'Provider To Be Authorized' are not included/not available for selection.
  10. Select search result/CPT Code in the 'Code Authorized' field and enter value for corresponding 'Units Authorized' field; if enabled, ensure that 'Estimated Liability Code' field value is populated based on Provider Fee Definition for selected 'Code Authorized'/'Units Authorized' field entries where applicable Provider Fee Definition is defined by Procedure Code Group for Contracting Provider.
  11. Enter/select values for any other fields in form as required/desired.
  12. Click 'Submit' button to file 'Service Authorization' form/record.
Topics
• Registry Settings • Service Authorizations • NX