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Avatar MSO 2023 Monthly Release 2023.02.01 Acceptance Tests

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Update 6 Summary | Details
Avatar MSO Automated Claim Processing and Service Adjudication
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 837 Health Care Claim Processing must be enabled and configured for system (via Avatar MSO '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 Avatar MSO '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 all posted inbound 837 claims/services are adjudicated (Approved/Denied) following 837 Professional/837 Institutional file posting (according to Avatar MSO adjudication criteria in Approve/Pend/Deny Rules Definition, service requirements, service authorization limits, etc).
  6. 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.
  7. 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.
  8. 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.
  9. Ensure that Avatar MSO Claim Processing batch(es) are closed following 837 file automated processing (and Vouchers/EOBs created if applicable) as defined in the 'Claim Processing Automation' form.
  10. 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.
Avatar MSO 'Create Voucher' Form/Function
Scenario 1: 'Create Voucher' - Form Verification
Specific Setup:
  • One or more service(s) in closed claims processing batch(es) eligible for Voucher inclusion
Steps
  1. Open Avatar MSO 'Create Voucher' form.
  2. Note - Acceptance testing may also be confirmed in Vouchers created via Avatar MSO Claim Processing Automation functions
  3. Select value for 'All or Individual Providers' (and select providers if 'Individual...').
  4. Enter value for 'Include Services From' and/or 'Include Services Through' date criteria fields (and any other Voucher creation criteria as desired).
  5. Click 'Submit' button to create Voucher for services within defined date range.
  6. In Voucher creation confirmation dialog, ensure that values displayed for 'Total Amount of Vouchers Created' and 'Total Number of Vouchers Created' correctly reflect/include all services within 'Include Services From' and 'Include Services Through' date range for EOB(s) included in Voucher.
  7. In case where an existing process/form session is already currently filing a Voucher - ensure user is presented with an error dialog noting 'Another Create Voucher process is still running. Please try again later' and the Voucher creation process/'Create Voucher' instance is not completed/filed.
Avatar MSO '835 Healthcare Claim Payment/Advice' Information
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Dictionary Update (MSO)
  • MSO EOB Message Customization
  • CPT Code Definition (MSO)
  • 835 Health Care Claim Payment/Advice (MSO)
Scenario 1: '835 Health Care Claim Payment/Advice' - Verification of CAS-2110 Claim Adjustment Reason Code/Remark Code Values
Specific Setup:
  • Avatar MSO Registry Setting 'Specify Adjustment (2110-CAS) Logic' must be enabled (with registry value including '3')
  • Avatar MSO Registry Setting 'Include Remark Codes (2110-LQ)' may optionally be enabled/disabled
  • The following dictionary codes/data elements must be defined (via Avatar MSO 'Dictionary Update' form):
  • 'Other Tabled Files' Data Element '(355) Adjustment Reason Code' (including '(357) Default Remark Code (2110-LQ-02)' Extended Dictionary value if utilizing Remark Codes)
  • 'Other Tabled Files' Data Element '(357) Default Remark Code' (if utilizing Remark Codes)
  • 'Other Tabled Files' Data Element '(351) Adjustment Code' (including '(354) Adjustment Group Code' / '(355) Adjustment Reason Code' / '(356) Adjustment Group Code 5010' Extended Dictionary values)
  • 'Adjustment Code'/'Remark Codes' value must be defined for Approve/Pend/Deny Rule 'Missing valid primary CPT Code' adjudication rule (via Avatar MSO 'MSO EOB Message Customization' form)
  • CPT Code(s) defined with 'Add On' CPT Code Category (via Avatar MSO 'CPT Code Definition' form)
  • EOB record(s) eligible for 835 outbound file inclusion and including service(s) denied due to 'Missing valid primary CPT Code' adjudication rule
Steps
  1. Open Avatar MSO '835 Health Care Claim Payment/Advice' form.
  2. Note - Acceptance testing may also be confirmed in 835 files created via Avatar MSO Claim Processing Automation functions
  3. Select 'Sort File' in the 'Options' field.
  4. Select 'Contracting Provider' value.
  5. Select EOB(s) for 835 outbound file inclusion in the 'Select EOB(s)' field - selecting EOB including service(s) denied due to 'Missing valid primary CPT Code' adjudication rule.
  6. Click 'Process' button.
  7. Ensure that in case where one or more EOB(s) including services denied due to 'Missing valid primary CPT Code' adjudication rule are selected for 835 sorting, the 'Process' action completes in timely manner, and that '835 Health Care Claim Payment/Advice Report' is displayed following 835 sorting completion.
  8. In '835 Health Care Claim Payment/Advice Report' results, ensure that Adjustment Group Code, Adjustment Reason Code and Remark Code (if utilized) values defined for the 'Missing valid primary CPT Code' adjudication rule are present for services.
  9. Close '835 Health Care Claim Payment/Advice Report' report viewer window.
  10. Select 'Create File On Server' in the 'Options' field.
  11. Select sorted 835 file in the 'Select File (Date - Time - EOB(s))' field.
  12. Click 'Process' button.
  13. Ensure that 835 Health Care Claim Payment/Advice output file is created on server (in output directory defined via Avatar MSO 'Set System Defaults' form).
  14. In 835 Health Care Claim Payment/Advice file created, ensure that Service Adjustment 2110-CAS Claim Adjustment Group Code/Claim Adjustment Reason Code segments/values are present for services denied due to 'Missing valid primary CPT Code' adjudication rule (and related Health Care Remark Code 2110-LQ segments/values if utilized).
Topics
• 837 Health Care Claim Professional • Claims Processing • 837 Health Care Claim Institutional • Create Voucher • NX • 835 Health Care Claim Payment/Advice
Update 9 Summary | Details
Avatar MSO 'Create EOB' Form/Function
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Retro Claim Adjudication
Scenario 1: 'Create EOB' - Verification of 'Create EOB By Fiscal Year' and 'Include In EOB Retros For Replaced Services Not On EOB' Registry Settings
Specific Setup:
  • Avatar MSO Registry Setting 'Include In EOB Retros For Replaced Services Not On EOB' must be enabled
  • Avatar MSO Registry Setting 'Create EOB By Fiscal Year' must be enabled ('MM/DD' Fiscal Year boundary date defined)
  • One or more claims/services in 'Closed' status Claims Processing Batch(es), included on Voucher and not yet included on EOB
  • One or more 'replacement' Retro Claim Adjudication entries not yet included on an EOB, for claims/services in different Fiscal Year period than claims/services for EOB inclusion above (as defined by 'Create EOB By Fiscal Year' Registry Setting date) and where original services have previously been included in EOB
  • Crystal Reports or other SQL tool
Steps
  1. Open 'Create EOB' form.
  2. Note - Acceptance testing may also be confirmed via Avatar MSO Claims Processing Automation EOB creation
  3. Select 'All' or 'Individual Providers' for EOB creation.
  4. Click 'Submit' button.
  5. Ensure EOB creation confirmation message is displayed on process completion.
  6. In EOB creation confirmation message, ensure that 'Total Amount of EOB(s) Created' value reflects/includes sum of all service 'Expected Disbursement' amounts and Retro Claim Adjudication entry/entries 'Take Back Amount' included in EOB(s) generated.
  7. In EOB creation confirmation message, ensure that 'Total Number of EOB(s) Created' value reflects total number of EOB(s) created - ensuring that distinct/multiple EOBs are created by Fiscal Year in case where claims/services in Claims Processing Batch(es) and 'replacement claim' Retro Claim Adjudication entries included in EOB creation criteria exist for different Fiscal Year periods (as defined by 'Create EOB By Fiscal Year' Registry Setting date), including Retro Claim Adjudication entries where original services have previously been included in EOB.
  8. Open Crystal Reports or other SQL reporting tool.
  9. In Avatar MSO SQL table 'SYSTEM.table_eob_core', ensure that distinct/multiple row(s) are present in table for all services and/or Retro Claim Adjudication entries included in EOB creation where distinct/multiple EOBs are created by Fiscal Year, including 'replacement claim' Retro Claim Adjudication entries where original services have previously been included in EOB.
  10. In Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications', ensure that 'EOBID' value is updated to newly created EOB number for all Retro Claim Adjudication entries included in EOB(s) including case where original services have previously been included in EOB.
Topics
• Registry Settings • Retro Claim Adjudication • NX • myAvatar/myAvatar NX
Update 19 Summary | Details
Avatar MSO 'Enable Fee Override in PM' Registry Setting
Scenario 1: 'Close Batch' - Avatar MSO to Cal-PM Parent System Service Filing, Verification of Service Filing With Fee Override Enabled for Services with Other Healthcare Coverage Information
Specific Setup:
  • Avatar Cal-PM Parent System is required for Acceptance Testing with Registry Setting 'Support MSO Other Healthcare Coverage' enabled
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
  • Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (set to '1','2', '3' or '4')
  • If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
  • 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
  • CPT Code/Revenue Code must be selected/included for Fee Override in filing to parent system (via Avatar 'Provider Fee Definition' form)
  • One or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
Steps
  1. Open Avatar MSO 'Close Batch' form.
  2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
  3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system.
  4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
  5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
  6. Open 'Client Ledger' form in parent Avatar Cal-PM system.
  7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
  8. Select 'Claim/Episode/All Episodes' value.
  9. Select 'Ledger Type' value.
  10. Click 'Process' button.
  11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
  12. For services originating via Avatar MSO and filed to Avatar Cal-PM parent system (where Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' and Avatar MSO Registry Setting 'Enable Fee Override in PM' are enabled):
  13. Services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM Client Ledger 'Charge' value for service(s) reflects the 'Allowed Amount' value from Avatar MSO Other Healthcare Coverage information for service(s)
  14. Note - Avatar Cal-PM 'Cost of Service'/'Guarantor Liability' value for service(s) originating in Avatar MSO with Other Healthcare Coverage information will reflect Client Ledger Charge/Allowed Amount value not including Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM
  15. Services not including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM 'Charge'/'Cost Of Service' (as well as 'Guarantor Liability') value for service(s) in Avatar Cal-PM reflects the selected/applicable Avatar MSO Fee Override Type (Expected Disbursement/Fee Table Amount/Total Charge), or PM Service Fee Table Amount where override not selected
Topics
• Registry Settings • MSO To Parent System Integration Mapping • Claims Processing • NX
Update 21 Summary | Details
Avatar MSO 'Plan Definition' form
Scenario 1: 'Plan Definition' - Form Verification
Specific Setup:
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO 'Plan Definition' form.
  2. Search/select existing Benefit Plan for update and click 'OK' button to open, or click 'New Plan' button to enter new Benefit Plan.
  3. Enter/select values for fields in 'Plan Definition' main/first section of form as required/desired.
  4. Navigate to 'Plan Coverage Definition' section of form.
  5. Select existing Plan Covered Services row and click 'Edit Selected Item' button, or click 'Add New Item' button to enter new Plan Covered Services row.
  6. Verify 'Plan Coverage Level Name' field is present in form; enter value for 'Plan Coverage Level Name'.
  7. Enter/select values for fields in 'Plan Coverage Definition' section of form as required/desired; enter/update additional Plan Covered Services row(s) as desired.
  8. Click 'Submit' button to file 'Plan Definition' form/record.
  9. Re-open Avatar MSO 'Plan Definition' form.
  10. Search/select previously filed/updated Benefit Plan for update and click 'OK' button to open.
  11. Navigate to 'Plan Coverage Definition' section of form.
  12. Select existing Plan Covered Services row and click 'Edit Selected Item' button.
  13. Ensure that previously entered/filed value is present in 'Plan Coverage Level Name' field for selected Plan Covered Services entry/row.
  14. Open Crystal Reports or other SQL reporting tool.
  15. In Avatar MSO SQL table 'SYSTEM.plan_covered_services', ensure that 'plan_coverage_level_name' field is present and reflects value filed in 'Plan Coverage Level Name' field in 'Plan Definition' form ('Plan Coverage Definition' section).
Topics
• Plan Definition • NX
Update 22 Summary | Details
MSO Case Default
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • MSO Case Default
  • MSO Case Default Fields
Scenario 1: MSO Case Default - form and field validation
Specific Setup:

N/A

Steps
  1. Open the ‘MSO Case Default’ form.
  2. Select a value in ‘MSO Case Default Form’.
  3. Select more than four values in ‘MSO Case Default Fields’. Note the order of selection.
  4. Verify that the ‘Maximum field warning’ message is received, and that it says: You cannot select more than 4 fields.
  5. Click [OK].
  6. Verify the ‘Current Order’ matches the items selected in ‘MSO Case Default Fields’.
  7. Click [Submit].
Topics
• Forms • NX
Update 25 Summary | Details
Avatar MSO 'Service Authorization Request' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Service Authorization Request
Scenario 1: 'Service Authorization Request' - Form Verification
Specific Setup:
  • Avatar MSO Registry Setting 'Display Requested Units Fields' must be enabled
Steps
  1. Open Avatar MSO 'Service Authorization Request' form.
  2. Enter/select client for Service Authorization Request entry.
  3. Enter/select value for 'Funding Source Authorization Is For' field (if value not defaulted in form).
  4. In case where user is logged into sub-system code, including use of Avatar ProviderConnect NX - Ensure that the 'Provider To Be Authorized' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code (as defined in 'ProviderConnect NX Defaults' form 'Associated Contracting Providers' field); ensure that the 'Provider To Be Authorized' lookup/selection/entry field is automatically populated with Contracting Provider applicable to/allowed for current sub-system code and disabled/read-only in case where only single 'Associated Contracting Provider' value is defined for sub-system code.
  5. Ensure that the 'Contracting Provider Program' field is populated with Contracting Provider Program(s) defined for/applicable to Contracting Provider selected in the 'Provider To Be Authorized' field, including case where 'Provider To Be Authorized' value is defaulted in form; select value in 'Contracting Provider Program' field.
  6. Enter/select values for 'Benefit Plan', 'Begin Date Of Authorization' and 'End Date Of Authorization' fields (and any other 'Service Authorization Request' form fields as required/desired).
  7. Select value in 'Authorization Grouping Or Individual Authorizations' field (and enter/select one or more CPT/Revenue Codes for authorization if applicable).
  8. Click 'Submit' button to file 'Service Authorization Request' form/record.
Topics
• Service Authorizations • NX
Update 28 Summary | Details
Avatar MSO to Avatar PM/Cal-PM Service Filing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • CPT Code Definition (MSO)
  • Electronic Billing
Scenario 1: 'Close Batch' - Avatar MSO to PM Parent System Service Filing, Verification of 837 Professional Bills For Primary/Add-On/Interactive Complexity CPT Codes
Specific Setup:
  • 'Maximum Service Information Per Claim Information (Maximum LX Per CLM)' field must be defined for applicable Guarantor/Program Billing Template (via Avatar PM/Cal-PM 'Guarantor/Program Billing Defaults' form)
  • Avatar MSO CPT Codes defined with 'Primary Code' / 'Add-On Code' / 'Interactive Complexity' CPT Code Category (via Avatar MSO 'CPT Code Definition' form)
  • One or more Avatar MSO originating claims containing 'Approved' status Primary and Add-On/Interactive Complexity service(s) eligible for filing to Avatar Cal-PM on Batch Closing (for outbound 837 Professional file inclusion via Avatar PM/Cal-PM 'Electronic Billing' form)
  • Note - Claims/services originating in Avatar MSO for Acceptance Testing must be filed subsequent to installation of Avatar MSO 2023 Update 28
Steps
  1. In Avatar MSO, create one or more claims containing both 'Approved' status Primary and one or more Add-On/Interactive Complexity service(s) via inbound 837 Health Care Claim Professional posting/filing and/or manual entry (i.e. 'Fast Service Entry' form).
  2. Open Avatar MSO 'Close Batch' form.
  3. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM/Cal-PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
  4. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status Primary and Add-On/Interactive Complexity service(s) in same/single claim eligible for filing to parent Avatar PM/Cal-PM system.
  5. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
  6. Click 'Submit' button to close batch/file services to parent Avatar PM/Cal-PM system.
  7. Open 'Client Ledger' form in parent Avatar PM/Cal-PM system.
  8. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
  9. Select 'Claim/Episode/All Episodes' value.
  10. Select 'Ledger Type' value.
  11. Click 'Process' button.
  12. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar PM/Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
  13. Close 'Client Ledger' form.
  14. Close charges for services in Avatar PM/Cal-PM via 'Close Charges' form (and/or Interim Billing Batch forms/functions if desired).
  15. Open Avatar PM/Cal-PM 'Electronic Billing' form.
  16. Note - Acceptance testing may also be confirmed via Avatar PM/Cal-PM 'Quick Billing' form/functionality
  17. Select 837 Professional in 'Billing Form' field.
  18. Enter/select 837 file sorting criteria, using values which will include service(s) originating in Avatar MSO with Primary and Add-On/Interactive Complexity service(s) in same/single claim
  19. Click 'Process' button to sort/generate 837 Professional file.
  20. Select 'Dump File' in the 'Billing Options' field (or select 'Create File On Server' to review output file directly).
  21. Select 'Print' in the 'Print Or Delete Report' field.
  22. Select 837 Professional file sorted which includes services originating in Avatar MSO, and click 'Process' button to display 837 outbound file data.
  23. In Avatar PM/Cal-PM 837 Professional/837 Institutional format outbound electronic billing file data - for services originating via Avatar MSO with Primary and Add-On/Interactive Complexity service(s) in same/single claim, ensure that Primary Service and all related Add-On Service(s)/Interactive Complexity Service(s) are included in same/single claim (multiple 2400-LX service line entries under same/single 2300-CLM iteration), regardless of the value specified in the Guarantor/Program Billing Defaults/Template 'Maximum Service Information Per Claim Information (Maximum LX Per CLM)' field/setting.
Topics
• MSO To Parent System Integration Mapping • CPT Code Definition • 837 Professional • Claims Processing • NX
 

Avatar_MSO_2023_Monthly_Release_2023.02.01_Details.csv