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Avatar MSO 2023 Monthly Release 2023.02.02 Acceptance Tests

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Update 8 Summary | Details
Avatar MSO 'Enable Authorize and Adjudicate on Per Stay Basis' Registry Setting
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Budget Tracking Account Setup
  • 837 Health Care Claim Professional
  • 837 Health Care Claim Institutional
  • File Import
  • File Import Report
  • Manual Batch Adjudication
  • Claim Processing (CMS 1500)
  • Claim Processing (UB-04)
  • Retro Claim Adjudication
Scenario 1: Avatar MSO Registry Settings - Verification of 'Enable Authorize and Adjudicate on Per Stay Basis' Registry Setting
Steps
  1. Open 'Registry Settings' form.
  2. Enter search value 'Enable Authorize and Adjudicate on Per Stay Basis' and click 'View Registry Settings' button.
  3. Ensure Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' is returned (under 'Avatar MSO -> Care Management -> Service Authorization' path).
  4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting "Y" adds the 'Authorize and Adjudicate on Per Stay Basis' field to the 'Service Authorization' form. This gives the user the ability to have claims adjudicated on a per stay basis. This means the first service with the authorization number will be approved at the per stay rate and the rest of the services with the same authorization number will be approved for zero dollars.

Select "N" to remove the field and functionality."

Scenario 2: 'Service Authorization' - Verification of 'Authorize and Adjudicate on Per Stay Basis' Registry Setting
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
  • Avatar MSO Registry Setting 'Enable Budget Tracking' may be optionally enabled
  • One or more client record(s) eligible for Service Authorization entry
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO 'Service Authorization' form.
  2. Note - Acceptance testing may also be confirmed via the Avatar MSO 'Budget Tracking Account Setup' form ('Member Service Authorization' section) where 'Enable Budget Tracking' Registry Setting is enabled
  3. Select Client ID for 'Service Authorization' entry.
  4. Click 'Add' button in 'Service Authorization' form pre-display to enter new record, or select existing row/record and click 'Edit' button to view/update existing record.
  5. 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.
  6. Ensure 'Authorize and Adjudicate on Per Stay Basis' field is present in form, with 'Yes' and 'No' selections available; select 'Yes' value for 'Authorize and Adjudicate on Per Stay Basis' field.
  7. Select 'Individual' in the 'Authorization Grouping Or Individual Authorizations' field.
  8. Select 'CPT Code' or 'Revenue Code' in the 'Procedure Code Type' field.
  9. Enter search term for CPT Code in 'Code Authorized (1)' field; select CPT Code/Revenue Code in 'Code Authorized (1)' field.
  10. Enter value '1' in 'Units Authorized (1)' field.
  11. Ensure that if any value other than '1' is entered in 'Units Authorized (1)' field, user is presented with error dialog noting 'Units Authorized (1) must be 1 for a Per Stay Authorization' and the entry is disallowed.
  12. Ensure that if 'Group' is selected in 'Authorization Grouping Or Individual Authorizations' field, user is presented with error dialog noting 'Authorization Grouping not allowed for a Per Stay Authorization' and the entry is disallowed.
  13. Ensure that on attempted entry/selection of 'Code Authorized (2)' values, user is presented with error dialog noting 'Only one procedure code is allowed for a Per Stay Authorization' and the entry is disallowed.
  14. Enter/select values for any other fields in form as required/desired.
  15. Click 'Submit' button to file 'Service Authorization' form/record.
  16. Following 'Service Authorization' form filing, click 'Yes' button in 'Do you want to return to the Pre-Display?' dialog.
  17. Select previously entered/updated Service Authorization row in form pre-display and click 'Edit' button to open.
  18. Ensure that previously selected/filed value is present in 'Authorize and Adjudicate on Per Stay Basis' field.
  19. Open Crystal Reports or other SQL reporting tool.
  20. In Avatar MSO SQL table 'SYSTEM.service_auth_detail', ensure that new fields' per_stay_auth_code'/'per_stay_auth_value' are present and reflect value selected/filed for 'Authorize and Adjudicate on Per Stay Basis' field in 'Service Authorization form.
  21. In Avatar MSO SQL table 'SYSTEM.service_auth_detail', ensure that new field 'per_stay_svcuniqueidnew' is present; this field will be populated via Avatar MSO Claim Entry/Claim Processing forms/functions with value linking Service Authorization row/record with Claims Processing Batch ID~Service ID attributed to the first/main per-stay approved/paid service for entry once service(s) have been filed.
Scenario 3: '837 Health Care Claim Professional' - Verification of 'Authorize and Adjudicate on Per Stay Basis' Registry Setting
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
  • Client with eligible Service Authorization record(s) valid for 837 Professional inbound file Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
  • 837 Health Care Claim Professional file(s) for compilation/posting including one or more valid claims/services
Steps
  1. Open Avatar MSO '837 Health Care Claim Professional' 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 Professional format file and click 'Process' button.
  5. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
  6. Click 'Process' button.
  7. In 837 Professional Compile Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
  8. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values will not be immediately reflected in 837 Professional Compile/Post Report information
  9. Select 'Post File' in the 'Options' field.
  10. Select compiled 837 Professional format file and click 'Process' button.
  11. In 837 Professional Post Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
  12. Avatar MSO Claim Processing batch(es) created for 837 Professional format claims/services will be adjudicated following file posting (and may also be adjudicated via 'Manual Batch Adjudication' form and/or 'Close Batch' function)
  13. Following 837 Professional format inbound file claim/service posting and batch/claim/service adjudication, open claims/services for review via 'Claim Processing (CMS 1500)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
  14. Navigate to 'Service Detail' section of form.
  15. Select service row and click 'Edit Selected Item'.
  16. For 837 Professional/CMS 1500 claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
  17. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
  18. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
  19. Applies to services associated to same/single Service Authorization in same or different 837 Professional files, in same or different claims and/or in same or different Claim Processing batch(es)
  20. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
  21. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
  22. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'
Scenario 4: '837 Health Care Claim Institutional' - Verification of 'Authorize and Adjudicate on Per Stay Basis' Registry Setting
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
  • Client with eligible Service Authorization record(s) valid for 837 Institutional inbound file Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
  • 837 Health Care Claim Institutional file(s) for compilation/posting including one or more valid claims/services
Steps
  1. Open Avatar MSO '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 - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
  8. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values will not be immediately reflected in 837 Institutional Compile/Post Report information
  9. Select 'Post File' in the 'Options' field.
  10. Select compiled 837 Institutional format file and click 'Process' button.
  11. In 837 Institutional Post Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
  12. Avatar MSO Claim Processing batch(es) created for 837 Institutional format claims/services will be adjudicated following file posting (and may also be adjudicated via 'Manual Batch Adjudication' form and/or 'Close Batch' function)
  13. Following 837 Institutional format inbound file claim/service posting and batch/claim/service adjudication, open claims/services for review via 'Claim Processing (UB-04)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
  14. Navigate to 'Service Detail' section of form.
  15. Select service row and click 'Edit Selected Item'.
  16. For 837 Institutional/UB-04 claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
  17. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
  18. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
  19. Applies to services associated to same/single Service Authorization in same or different 837 Institutional files, in same or different claims and/or in same or different Claim Processing batch(es)
  20. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
  21. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
  22. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'
Scenario 5: File Import - Service Authorization - Verification of Member Service Authorization
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
  • One or more client record(s) eligible for Service Authorization entry/import
  • Avatar MSO 'Service Authorization - Member' Import File containing one or more valid import rows where value is defined for 'Authorize and Adjudicate on Per Stay Basis' (field/segment 441)
Steps
  1. Open 'File Import' form in Avatar Cal-PM.
  2. Select File Type '[Avatar MSO] Service Authorization - Member'.
  3. Click 'Process Action' button.
  4. Select Avatar MSO Service Authorization - Member import file and click 'Open' button.
  5. Select 'Compile/Validate File' in 'Action' field.
  6. Select loaded import file and click 'Process Action' button.
  7. Ensure that 'Compile/Validate File' action completes, and message 'Compiled' or '(File Name) contains one or more errors. These errors can be reviewed using 'Print Errors' action' is displayed.
  8. Click 'OK' button.
  9. Select 'Post File' in 'Action' field.
  10. Select compiled Avatar MSO Service Authorization - Member import file and click 'Process Action' button.
  11. Ensure that 'Post' action completes, and message 'Posted' and/or 'The selected file contains one or more lines with compilation errors. Only those lines without compilation errors will be posted' is displayed.
  12. Select 'Print Errors' in 'Action' field for compiled import file with one or more errors.
  13. Select compiled import file with any errors and click 'Process Action' button.
  14. In '[Avatar MSO] Service Authorization - Member' File Import Error report, ensure that all invalid/errored import row(s) where 'Authorize and Adjudicate on Per Stay Basis' is defined as 'Y' and 'Units Authorized' is not defined as '1' or more than one 'Code Authorized' entry exists are included in report with segment/value reference and error message detail.
  15. File Import Error examples:
  16. 'Units Authorized (1) must be 1 for a Per Stay Authorization'
  17. 'Only one procedure code is allowed for a Per Stay Authorization'
  18. Open Avatar MSO 'Service Authorization' form.
  19. Select Client ID for 'Service Authorization' view/edit where File Import record/row posted.
  20. Select Service Authorization row/record filed via File Import in form pre-display and click 'Edit' button to open.
  21. Ensure that imported/filed value is present in 'Authorize and Adjudicate on Per Stay Basis' field.
Scenario 6: Avatar MSO Claim Processing - Verification of 'Authorize and Adjudicate on Per Stay Basis' Registry Setting
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
  • Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
Steps
  1. Enter two or more claims/services in Avatar MSO, where services are associated to single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
  2. Note - Manual claim/service entry may be done via 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms (in addition to 837 inbound file posting)
  3. Adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, nightly automatic adjudication process and/or 'Close Batch' function).
  4. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values may not be immediately reflected in Claim Processing forms during initial service entry
  5. Following batch/claim/service adjudication, open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
  6. Navigate to 'Service Detail' section of form.
  7. Select service row and click 'Edit Selected Item'.
  8. For claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
  9. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
  10. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
  11. Applies to services associated to same/single Service Authorization in same or different claims and/or in same or different Claim Processing batch(es)
  12. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
  13. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
  14. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'
Scenario 7: 'Retro Claim Adjudication' - Verification of 'Authorize and Adjudicate on Per Stay Basis' Registry Setting
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
  • One or more services in 'Closed' status Claim Processing batch(es) eligible for Retro Claim Adjudication entry, associated to Service Authorization record(s) where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
Steps
  1. Open Avatar MSO 'Retro Claim Adjudication' form.
  2. Note - Acceptance testing may also be confirmed via 837 Health Care Claim Professional/Institutional 'Void' and/or 'Replacement' Retro Claim Adjudication entries and/or '[Avatar MSO] Retro Claim Adjudication' File Import
  3. Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field.
  4. Select 'Claim' and 'Date of Service/Procedure' values for Retro Claim Adjudication entry/update, selecting service which is first service associated to Per-Stay Service Authorization (service which was Approved with 'Expected Disbursement' value from full Provider Fee Definition).
  5. On selection of first service associated to Per-Stay Service Authorization, ensure user is presented with an alert dialog noting 'The selected Procedure is the primary Per Stay Procedure. If Updated Approved Units are set to zero then all other procedures in the Stay will be updated to have zero Updated Approved Units also.'
  6. Enter zero value for 'Updated Approved Units' and allow system calculation of updated values or directly set 'Take Back Units' and 'Updated Disbursement Amount' values for service (so that Retro Claim Adjudication entry is full service takeback/void entry).
  7. Select value for 'Adjustment Code' field if not defaulted automatically.
  8. Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
  9. On entry/filing of full takeback/void Retro Claim Adjudication for first service associated to Per-Stay Service Authorization - ensure that additional Retro Claim Adjudication entries are automatically created in system for all other Per-Stay services in 'Closed' status batches associated to same Service Authorization, with 'Updated Approved Units' set to zero.
  10. Applies to services associated to same/single Service Authorization in same or different claims and/or in same or different Claim Processing batch(es)
  11. 'Comments' field for additional/automatically created Retro Claim Adjudication entries will include value 'Included with Per Stay Service.'
  12. Retro Claim Adjudication entries created for additional/secondary claims/services associated to Per-Stay Service Authorization may be confirmed via 'Retro Claim Adjudication' form 'Edit' selection (or reviewed directly via Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications')
Topics
• Registry Settings • NX • Service Authorizations • 837 Health Care Claim Professional • Claims Processing • 837 Health Care Claim Institutional • File Import • Retro Claim Adjudication
Update 14 Summary | Details
Plan Definition - Annual dollar limit
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • Financial Eligibility
  • Funding Source Registration
  • CPT Code Definition (PM)
  • MSO to Parent System Integration Mapping
  • Plan Definition
  • Service Fee/Cross Reference Maintenance
  • Dynamic Form - Edit Service Fee Definition
  • Approve/Pend/Deny Rules Definition
  • Claim Processing (CMS 1500)
Scenario 1: Claim Processing (CMS 1500) - Validating Annual Dollars Exhausted for the claim/service for the services over the annual dollar limit
Specific Setup:
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • CPT Code Definition:
  • An existing CPT code is identified, or a new CPT code is created. Note the CPT code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified. The 'Annual Maximum Dollars' is set to desired value.
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have at least one registration records with at least 1 license record. Note the performing provider number and name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated to include the performing provider added above. Note the contracting provider number and name.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, CPT codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record.
  • Service Authorization:
  • Create a new approved service authorization covering a CPT code created above.
  • Batch Creation:
  • Create a new batch. Note the batch number/name.
  • Approve/Pending/Deny Rule definition:
  • All Claim Processing Rules For Overall Plan Limitations are set to desired value.
Steps
  1. Open the 'Claim Processing (CMS 1500)' form.
  2. Select desired batch.
  3. Enter an ID in the ‘Member Name Or ID’ field.
  4. Enter a provider name in the ‘Provider’ field.
  5. Go to the ‘Service Detail’ section.
  6. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  7. Enter a date in the ‘Date Of Service’ field
  8. Enter a procedure code in the ‘Procedure Code’ field.
  9. Enter desired amount in the ‘Total Charge’ field.
  10. Enter desired number in the ‘Service Units’ field.
  11. Enter a number in the ‘Duration(Minutes)’ field.
  12. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  13. Click the ‘Display Valid Authorizations’ button.
  14. Verify the ‘Claim Status’ field is set to ‘Approved’.
  15. Submit the form.
  16. Open the 'Service Authorization' for the client.
  17. Add a new service for the different date. Note the authorization number.
  18. Open the 'Claim Processing (CMS 1500)' form.
  19. Select desired batch.
  20. Enter an ID in the ‘Member Name Or ID’ field.
  21. Enter a provider name in the ‘Provider’ field.
  22. Go to the ‘Service Detail’ section.
  23. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  24. Enter a date in the ‘Date Of Service’ field.
  25. Enter a procedure code in the ‘Procedure Code’ field.
  26. Enter amount in the ‘Total Charge’ field such that it exceeds the annual dollar limit defined in the plan definition.
  27. Enter desired number in the ‘Service Units’ field.
  28. Enter a number in the ‘Duration(Minutes)’ field.
  29. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  30. Select the system generated authorization number from the above step for the service.
  31. Click the ‘Display Valid Authorizations’ button.
  32. Verify the ‘Claim Status’ field is set to ‘Approved’.
  33. Open the 'Service Authorization' for the client.
  34. Verify the explanation of benefit displays the overall annual dollars exhausted message.
  35. Submit the form.
Claim Processing (CMS 1500) - Third Party Adjudication Data section
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • Financial Eligibility
  • Diagnosis
  • CPT Code Definition (PM)
  • Plan Definition
  • Claim Processing (CMS 1500)
  • Claim Processing (UB-04)
  • Revenue Code Definition (PM)
  • Remittance Processing Widget
Scenario 1: Claim Processing (CMS 1500) - Validating COB Adjustment Data in the 'Third Party Adjudication' subsequent grid
Specific Setup:
  • Registry Settings:
  • The 'Add Support For The Input Of Third Party Payer Amounts' set to '2'.
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • CPT Code Definition:
  • An existing CPT code is identified, or a new CPT code is created. Note the CPT code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified. Note the plan id/name.
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have at least one registration records with at least 1 license record. Note the performing provider number and name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated to include the performing provider added above. Note the contracting provider number and name.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, CPT codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record.
  • Service Authorization:
  • Create a new service authorization covering a CPT code created above.
  • Batch Creation:
  • Create a new batch. Note the batch number/name. Note the batch name/number.
Steps
  1. Open the 'Claim Processing (CMS 1500)' form.
  2. Select desired batch.
  3. Enter an ID in the ‘Member Name Or ID’ field.
  4. Enter a provider name in the ‘Provider’ field.
  5. Go to the ‘Service Detail’ section.
  6. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  7. Enter a date in the ‘Date Of Service’ field
  8. Enter a procedure code in the ‘Procedure Code’ field.
  9. Enter an amount in the ‘Total Charge’ field.
  10. Enter a number in the ‘Service Units’ field.
  11. Enter a number in the ‘Duration(Minutes)’ field.
  12. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  13. Click the ‘Display Valid Authorizations’ button.
  14. Verify the ‘Claim Status’ field is set to ‘Approved’ or 'Denied' or 'Pended'.
  15. Click the ‘Enter Third Party Adjudication Data’ button.
  16. Verify the ‘Third Party Adjudication’ grid displays no data.
  17. Click the ‘New Row’ button.
  18. Enter a value in all the fields.
  19. Click on the ‘View’ button.
  20. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields with no data.
  21. Click the ‘New Row’ button to add the adjustment information for the service.
  22. Select a code in the ‘CAS adjustment Group Code’ field.
  23. Select a code in the ‘Adjustment Reason Code 1’ field.
  24. Enter an amount in the ‘Amount 1’ field.
  25. Enter a number in the ‘Quantity 1’ field.
  26. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  27. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  28. Click the ‘Submit’ button to save the claim information.
  29. Open the 'Claim Processing (CMS 1500)' form again.
  30. Select desired batch.
  31. Enter an ID in the ‘Member Name Or ID’ field.
  32. Enter a provider name in the ‘Provider’ field.
  33. Go to the ‘Service Detail’ section.
  34. Click the ‘Edit Item’ button to edit a row which is recently created.
  35. Click the ‘Enter Third Party Adjudication Data’ button.
  36. Verify the ‘Third Party Adjudication’ grid displays previously entered data correctly.
  37. Click on the ‘View’ button.
  38. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields with the data previously entered.
  39. Click the ‘New Row’ button to add new adjustment information for the service.
  40. Select a desired code in the ‘CAS adjustment Group Code’ field that is different from the code used in the above step.
  41. Select a desired code in the ‘Adjustment Reason Code 1’ field that is different from the code used in the above step.
  42. Enter an amount in the ‘Amount 1’ field.
  43. Enter a number in the ‘Quantity 1’ field.
  44. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  45. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  46. Click the ‘Submit’ button to save the claim information.
  47. Open the 'Claim Processing (CMS 1500)' form again.
  48. Select desired batch.
  49. Enter an ID in the ‘Member Name Or ID’ field.
  50. Enter a provider name in the ‘Provider’ field.
  51. Go to the ‘Service Detail’ section.
  52. Click the ‘Edit Item’ button to edit a row which is created in the above steps.
  53. Click the ‘Enter Third Party Adjudication Data’ button.
  54. Verify the ‘Third Party Adjudication’ grid correctly displays previously entered data.
  55. Click [View].
  56. Verify the grid displays two rows with the correct CAS adjustment Group Code, Adjustment Reason Code and Amount fields with the data entered in above steps.
Scenario 2: Claim Processing (UB 04) - Validating COB Adjustment Data in the 'Third Party Adjudication' subsequent grid
Specific Setup:
  • Registry Settings:
  • The 'Add Support For The Input Of Third Party Payer Amounts' set to '2'.
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • Revenue Code Definition:
  • An existing revenue code is identified, or a new revenue code is created. Note the revenue code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified. Note the plan id/name.
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have at least one registration records with at least 1 license record. Note the performing provider number and name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated to include the performing provider added above. Note the contracting provider number and name.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, revenue codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record.
  • Service Authorization:
  • Create a new service authorization covering a revenue code created above.
  • Batch Creation:
  • Create a new batch. Note the batch number/name. Note the batch name/number.
Steps
  1. Open the 'Claim Processing (UB 04)' form.
  2. Select desired batch.
  3. Enter an ID in the ‘Member Name Or ID’ field.
  4. Enter a provider name in the ‘Provider’ field.
  5. Go to the ‘Service Detail’ section.
  6. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  7. Enter a date in the ‘Date Of Service’ field
  8. Enter a procedure code in the ‘Procedure Code’ field.
  9. Enter an amount in the ‘Total Charge’ field.
  10. Enter a number in the ‘Service Units’ field.
  11. Enter a number in the ‘Duration(Minutes)’ field.
  12. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  13. Click the ‘Display Valid Authorizations’ button.
  14. Verify the ‘Claim Status’ field is set to ‘Approved’ or 'Denied' or 'Pended'.
  15. Click the ‘Enter Third Party Adjudication Data’ button.
  16. Verify the ‘Third Party Adjudication’ grid displays no data.
  17. Click the ‘New Row’ button.
  18. Enter a value in all the fields.
  19. Click on the ‘View’ button.
  20. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields with no data.
  21. Click the ‘New Row’ button to add the adjustment information for the service.
  22. Select a code in the ‘CAS adjustment Group Code’ field.
  23. Select a code in the ‘Adjustment Reason Code 1’ field.
  24. Enter an amount in the ‘Amount 1’ field.
  25. Enter a number in the ‘Quantity 1’ field.
  26. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  27. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  28. Click the ‘Submit’ button to save the claim information.
  29. Open the 'Claim Processing (UB 04)' form again.
  30. Select desired batch.
  31. Enter an ID in the ‘Member Name Or ID’ field.
  32. Enter a provider name in the ‘Provider’ field.
  33. Go to the ‘Service Detail’ section.
  34. Click the ‘Edit Item’ button to edit a row which is created in the above steps.
  35. Click the ‘Enter Third Party Adjudication Data’ button.
  36. Verify the ‘Third Party Adjudication’ grid correctly displays previously entered data.
  37. Click on the ‘View’ button.
  38. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields correctly display previously entered data.
  39. Click the ‘New Row’ button to add new adjustment information for the service.
  40. Select a desired code in the ‘CAS adjustment Group Code’ field that is different from the code used in the above step.
  41. Select a desired code in the ‘Adjustment Reason Code 1’ field that is different from the code used in the above step.
  42. Enter an amount in the ‘Amount 1’ field.
  43. Enter a number in the ‘Quantity 1’ field.
  44. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  45. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  46. Click the ‘Submit’ button to save the claim information.
  47. Open the 'Claim Processing (UB 04)' form again.
  48. Select desired batch.
  49. Enter an ID in the ‘Member Name Or ID’ field.
  50. Enter a provider name in the ‘Provider’ field.
  51. Go to the ‘Service Detail’ section.
  52. Click the ‘Edit Item’ button to edit a row which is created in the above steps.
  53. Click the ‘Enter Third Party Adjudication Data’ button.
  54. Verify the ‘Third Party Adjudication’ grid correctly displays previously entered data.
  55. Click [View].
  56. Verify the grid displays two rows with the correct CAS adjustment Group Code, Adjustment Reason Code and Amount fields correctly display previously entered data.
Import/Export File Configuration - Process MSO 837P files
Scenario 1: Import/Export Configurations form - Processing multiple automated inbound 837 professional / Institutional
Specific Setup:
  • New directories are created or an existing directory is identified to store the 837 files that needs to be processed, the files that are successfully processed and the error files.
  • Import/Export File Configuration:
  • Process File Path = An existing directory path for 837P files that needs to be processed.
  • Error File Path = An existing directory path to store error files.
  • Default 837 Professional Filing User = the logged in user.
  • Processing Interval = Desired value for how often the 837P directory (Process File Path field) will be checked for a file.
  • Interval Units = Desired unit in Hours, Minutes, or Seconds.
  • Auto-Process Actions = Desired value
  • Maximum Simultaneous File Processes = maximum number of simultaneous file compilation processes allowed for automatic 837 processing. Note the value.
  • Post Batch With Critical Errors = Desired option
  • Processed Folder File Path = Desired path for the new sub folder for processed files
Steps
  1. Place multiple 837 Professional and/or Institutional inbound files in the 'Process' directory.
  2. Check the 'Process' directory after time added to the 'Processing Interval' field.
  3. Validate that the files are processed successfully and moved to 'Error' or 'Success' directory.
Topics
• Claims Processing • NX
Update 18 Summary | Details
Avatar MSO 837 Professional/837 Institutional Health Care Claim Processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Guarantors/Payors
  • Funding Source/Guarantor Mapping
  • Benefit Enrollment and Maintenance (834)
  • 837 Health Care Claim Professional
  • 837 Health Care Claim Professional - Error Report
  • 837 Health Care Claim Institutional
  • 837 Health Care Claim Institutional - Error Report
Scenario 1: '837 Health Care Claim Professional' - Verification of Funding Source Determination
Specific Setup:
  • Avatar MSO Registry Setting 'Determine Funding Source By Policy Number' must be enabled
  • Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
  • Avatar PM Guarantor where 'Validate Guarantor via Avatar Eligibility Tables' is set to 'Yes' (via Avatar PM 'Guarantors/Payors' form)
  • 837 Professional claims/services for Avatar MSO Funding Source mapped to PM Guarantor and where 'Validate via Avatar Eligibility Tables' is selected for 'Eligibility Validation Method' (via Avatar MSO 'Funding Source/Guarantor Mapping' form)
  • 837 Professional claims/services for Avatar MSO Contracting Provider where 'Eligible Funding Source' field is not defined and/or 'Use Eligible Funding Source to Determine Funding Source for 837 Processing' field is set to 'No' (via Avatar MSO 'Contracting Provider Registration' form)
  • Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' for PATID/Subscriber Unique ID)
  • 837 Professional format inbound file containing claims/services successfully compiled for Contracting Provider and Member/Client
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO '837 Health Care Claim Professional' 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 Professional format file and click 'Process' button.
  5. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
  6. Click 'Process' button.
  7. In 837 Professional Compile Report - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client.
  8. Note - Avatar MSO Funding Source determined for 837 claims/services will be Funding Source which is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID (in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov') and where Date of Service is covered by eligibility information/Guarantor (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date')
  9. Note - If Avatar PM eligibility data for Member/Client does not include Date of Service (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date'), Funding Source for 837 claims/services will not be determined via eligibility information method
  10. Note - If no eligibility data exists in Avatar PM for Member/Client, Funding Source for 837 claims/services will not be determined via eligibility information method
  11. Note - If more than one Avatar MSO Funding Source is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID, Funding Source for 837 claims/services will not be determined via eligibility information method
  12. Select 'Post File' in the 'Options' field.
  13. Select compiled 837 Professional format file and click 'Process' button.
  14. In 837 Professional Post Report - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client (as detailed above).
  15. For any 837 Professional files where Funding Source cannot be determined for one or more Member/Client claims - Select 'Run Error Report' in the 'Options' field.
  16. Select compiled/Posted 837 Professional format file and click 'Process' button.
  17. In 837 Professional Error Report - ensure that in case where Funding Source cannot be determined for inbound 837 claim/service information, claim/services are not compiled and are listed in 837 Professional Error Report with 'Funding Source not found based on policy number' error condition.
  18. 837 Error Message Example: 'Funding Source not found based on policy number: 123456A and service date: 03/01/2023 for member: 123'
  19. Open 'Batch Creation' form.
  20. Select batch created via 837 Professional inbound file posting.
  21. Ensure that 'Funding Source' value for batch is present/same as determined by 837 Professional file compilation/posting.
Scenario 2: '837 Health Care Claim Institutional' - Verification of Funding Source Determination
Specific Setup:
  • Avatar MSO Registry Setting 'Determine Funding Source By Policy Number' must be enabled
  • Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
  • Avatar PM Guarantor where 'Validate Guarantor via Avatar Eligibility Tables' is set to 'Yes' (via Avatar PM 'Guarantors/Payors' form)
  • 837 Professional claims/services for Avatar MSO Funding Source mapped to PM Guarantor and where 'Validate via Avatar Eligibility Tables' is selected for 'Eligibility Validation Method' (via Avatar MSO 'Funding Source/Guarantor Mapping' form)
  • 837 Professional claims/services for Avatar MSO Contracting Provider where 'Eligible Funding Source' field is not defined and/or 'Use Eligible Funding Source to Determine Funding Source for 837 Processing' field is set to 'No' (via Avatar MSO 'Contracting Provider Registration' form)
  • Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' for PATID/Subscriber Unique ID)
  • 837 Institutional format inbound file containing claims/services successfully compiled for Contracting Provider and Member/Client
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO '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 - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client.
  8. Note - Avatar MSO Funding Source determined for 837 claims/services will be Funding Source which is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID (in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov') and where Date of Service is covered by eligibility information/Guarantor (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date')
  9. Note - If Avatar PM eligibility data for Member/Client does not include Date of Service (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date'), Funding Source for 837 claims/services will not be determined via eligibility information method
  10. Note - If no eligibility data exists in Avatar PM for Member/Client, Funding Source for 837 claims/services will not be determined via eligibility information method
  11. Note - If more than one Avatar MSO Funding Source is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID, Funding Source for 837 claims/services will not be determined via eligibility information method
  12. Select 'Post File' in the 'Options' field.
  13. Select compiled 837 Institutional format file and click 'Process' button.
  14. In 837 Institutional Post Report - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client (as detailed above).
  15. For any 837 Institutional files where Funding Source cannot be determined for one or more Member/Client claims - Select 'Run Error Report' in the 'Options' field.
  16. Select compiled/Posted 837 Institutional format file and click 'Process' button.
  17. In 837 Institutional Error Report - ensure that in case where Funding Source cannot be determined for inbound 837 claim/service information, claim/services are not compiled and are listed in 837 Institutional Error Report with 'Funding Source not found based on policy number' error condition.
  18. 837 Error Message Example: 'Funding Source not found based on policy number: 123456A and service date: 03/01/2023 for member: 123'
  19. Open 'Batch Creation' form.
  20. Select batch created via 837 Institutional inbound file posting.
  21. Ensure that 'Funding Source' value for batch is present/same as determined by 837 Institutional file compilation/posting.
Topics
• Registry Settings • 837 Health Care Claim Professional • NX • 837 Health Care Claim Institutional
Update 20 Summary | Details
Contracting Provider Registration - Edit a performing provider.
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Performing Provider Registration
Scenario 1: Contracting Provider Registration - Editing an existing contracting provider to add new performing provider information with 2 registrations record and one license record
Specific Setup:
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have 2 registration records with at least 1 license record.
  • For the first registration - Enter registration start/end date. Do not enter any license information.
  • For the second registration - Enter registration start/end date. Enter license information.
  • Note the performing provider name, number, registration dates for both the registration record and license information.
  • Contracting Provider Registration:
  • Identify an existing contracting provider registration. Note the contracting provider name and number.
Steps
  1. Open the 'Contracting Provider Registration' form.
  2. Select desired contracting provider.
  3. Edit the existing registration.
  4. Go to the 'Performing Provider information' section.
  5. Add the new performing provider that is identified in the setup section.
  6. Make sure the performing provider registration shows the 1st registration. If not, select the first registration.
  7. Go to the 'Performing Provider License Information' section.
  8. Verify that no rows are loaded as the first registration does not have license information created.
  9. Add the new performing provider again that is identified in the setup section.
  10. Select the second registration.
  11. Go to the 'Performing Provider License Information' section.
  12. Verify the performing provider license information loaded correctly for the second registration.
  13. Submit the form.
  14. Open the 'Contracting Provider Registration' form again.
  15. Select desired contracting provider.
  16. Edit the existing registration.
  17. Go to the 'Performing Provider information' section.
  18. Edit the second registration for the performing provider records again.
  19. Verify the 'Performing Provider License Information' section displays correct information for the second registration,
  20. Verify the record updated successfully.
Claim Processing (CMS 1500) - Registry setting 'Require Performing Provider'=Y.
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Claim Processing (CMS 1500)
  • Authorization Selection - No Authorizations On File Error
  • Claim Processing with Override (CMS 1500)
Scenario 1: Claim Processing (CMS 1500) - Validating approved service when the total charge is modified and performing provider is required.
Specific Setup:
  • Registry 'Avatar MSO->Claims Processing->Service Detail->->->Require Performing Provider' is set to Y.
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • CPT Code Definition:
  • An existing CPT code is identified, or a new CPT code is created. Note the CPT code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified.
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have at least one registration records with at least 1 license record. Note the performing provider number and name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated to include the performing provider added above. Note the contracting provider number and name.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, CPT codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record.
  • Service Authorization:
  • Create a new approved service authorization covering a CPT code created above.
  • Create a new batch. Note the batch number/name.
Steps
  1. Open the 'Claim Processing CMS 1500' form.
  2. File an approved service with a performing provider selected.
  3. Go back in the form to edit the approved service.
  4. Change the 'Total Charge'.
  5. Verify the service stays approved.
Topics
• Contracting Provider Registration • NX • Claims Processing
Update 26 Summary | Details
Service Authorization
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Registry Settings (MSO)
Scenario 1: 'Service Authorization Request' - Form Verification
Specific Setup:
  • Avatar MSO Registry Setting: 'Display Requested Units Fields' must be enabled
  • Avatar MSO Registry Setting: 'Require Current Authorization Status Reason' has desired value to make the 'Current Authorization Status Reason' to be optional or required. Note the value selected.
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. Validate that the 'Current Authorization Status Reason' works as selected in the 'Require Current Authorization Status Reason' registry setting.
  8. Select value in 'Authorization Grouping Or Individual Authorizations' field (and enter/select one or more CPT/Revenue Codes for authorization if applicable).
  9. Click 'Submit' button to file 'Service Authorization Request' form/record.
Service Authorization
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Registry Settings (MSO)
Scenario 1: 'Service Authorization' - Form Pre-Display 'Delete' Verification
Specific Setup:
  • MSO Registry Setting: Set Service Authorization Pre-Display' contains desired values. Note the values.
  • Avatar ProviderConnect NX module must be installed/present
  • One or more Service Authorization record(s) for deletion via form pre-display
Steps
  1. Open Avatar MSO 'Service Authorization' form (or 'Service Authorization Request' form).
  2. Select Client ID/record for 'Service Authorization' entry/display.
  3. In 'Service Authorization' form pre-display, ensure that existing Service Authorization records for selected client are present/displayed, and that each column selected in the 'Set Service Authorization Pre-Display' registry is included in the display.
  4. Select existing Service Authorization record/row in pre-display and click 'Delete' button.
  5. Ensure user is presented with deletion confirmation dialog, noting 'Are you sure you want to delete this item?'; click 'Yes' button to proceed.
  6. Ensure selected Service Authorization record/row is deleted from system and is no longer present in 'Service Authorization' pre-display (re-opening 'Service Authorization' form/pre-display if necessary).
  7. In case where selected Service Authorization record/row has existing service(s) associated to authorization, ensure error dialog is displayed, noting 'This Authorization has already been claimed. Deletion is not permitted' and selected Service Authorization record/row is not deleted.
Topics
• Service Authorizations • NX
Update 27 Summary | Details
Fast Service Entry
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Registry Settings (MSO)
  • Admission (Outpatient)
  • Diagnosis
  • Financial Eligibility
  • MSO to Parent System Integration Mapping
  • Claim Processing (CMS 1500)
  • Claim Service Detail Override Warning
Scenario 1: Fast Service Entry - Claim Status Over-Ride - Re-Adjudicated
Specific Setup:
  • Client record eligible for claim/service entry.
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
  2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
  6. Enter/select values in all other service detail fields in form as required/desired.
  7. Verify the Claim Status is set to the correct value for the authorization record.
  8. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
  9. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es). Note the batch number.
  10. Open 'Manual Batch Adjudication' to select and process the batch,
  11. Open desired 'Claim Processing for to review the batch.
  12. Ensure that the 'Claim Status' is correct.
  13. Close the form.
Claims Adjudication Rules Definition
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • CPT Code Definition (PM)
  • Revenue Code Definition (PM)
  • Service Fee/Cross Reference Maintenance
  • Claims Adjudication Rules Definition
  • Diagnosis
  • Financial Eligibility
  • Procedure Code Group Definition
  • Program Maintenance
  • Funding Source Registration
  • Plan Definition
  • MSO to Parent System Integration Mapping
  • Claim Processing (CMS 1500)
  • Manual Batch Adjudication
  • Claim Processing (UB-04)
Scenario 1: Claims Adjudication Rules Definition - Procedure Code Grouping that contains CPT/Revenue codes with colons.
Specific Setup:
  • CPT Code Definition and/or Revenue Code Definition exists where a colon is in the code (Ex: '90834:93' or '910:25').
  • Claims Adjudication Rules Definition:
  • Desired rules exist for desired rule types: 'Comparison', 'Existence', and/or 'Limit' that contain the CPT Code Definition above, or the Revenue Code Definition above.
  • Note the rules and conditions of the rules.
  1. Client record eligible for claim/service entry.
Steps
  1. Use ‘Batch Creation’ to create a batch’.
  2. Using the desired ‘Claim Processing’ form create services, for the batch, that tests the conditions of the rules noted in setup.
  3. Verify that the status is correct for the service(s) based on the rule definitions.
  4. Submit the form.
  5. Use ‘Manual Batch Adjudication’ to manually adjudicate the batch.
  6. Using the desired ‘Claim Processing’ form review the service and the status, ensuring that the status is correct for the rule definition.
Topics
• Claims Processing • NX
Update 29 Summary | Details
Avatar MSO '837 Health Care Claim Institutional'
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 - Post 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 not including 2300 DTP Admission Date loop/segment/value
  • Optionally - 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) does not include 2300 DTP Admission Date loop/segment/value, ensure that claim/service(s) are successfully compiled (and are included in 837 compile report).
  8. In 837 Institutional Compile Report - in case where one or more claim(s) includes an invalid 2300 DTP Admission Date value, ensure that claim/service(s) are not successfully compiled (and are not included in 837 compile report).
  9. Select 'Run Error Report' in the 'Options' field, and select compiled 837 Institutional file.
  10. 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.'
  11. Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
  12. Click 'Process' button.
  13. In 837 Institutional Post Report - in case where one or more claim(s) does not include 2300 DTP Admission Date loop/segment/value, ensure that claim/service(s) are successfully posted (and are included in 837 compile report).
  14. In 837 Institutional Post Report - in case where one or more claim(s) includes 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 'Claim Acknowledgement (277CA) File'
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Professional
  • Claim Acknowledgement (277CA) File
  • 837 Health Care Claim Institutional
Scenario 1: 'Claim Acknowledgement (277CA) File' - Verification of Claim Acknowledgement File Status Service Information (Zero-Charge Claims/Services)
Specific Setup:
  • File path for 277CA Claim Acknowledgement file creation must be defined in the 'Output Directory' field for system (via Avatar MSO 'Set System Defaults' or 'Import/Export File Configuration' form)
  • 277CA Claim Acknowledgment file may optionally be enabled for automatic generation (via Avatar MSO 'Import/Export File Configuration' form)
  • 837 Professional and/or Institutional format inbound file(s) for compilation/posting including one or more zero-charge claims/services
  • Crystal Reports or other SQL reporting tool
Steps
  1. Using Avatar MSO '837 Health Care Claim Professional' and/or '837 Health Care Claim Institutional' forms (or via Avatar MSO automated 837 file processing), load/compile/post inbound 837 file(s).
  2. Open the Avatar MSO 'Claim Acknowledgement (277CA) File' form.
  3. 277CA file generation/content review may also be confirmed directly in system output directory where automatic 277CA file generation is enabled
  4. Select 'Create File On Server' in 'Options' field.
  5. Select 'Submission Type' field value ('Institutional' or 'Professional').
  6. Select 837 file for Claim Acknowledgement (277CA) file creation.
  7. Click 'Process' button.
  8. Ensure that for selected 837 file, Claim Acknowledgement (277CA) file is created on server in defined directory.
  9. This may be confirmed via the 'Claim Acknowledgement (277CA) File' form 'Run Report' or 'Dump File' options, and/or by reviewing files in 277CA output directory
  10. Select 'Dump File' in 'Options' field.
  11. Select 'Submission Type' field value ('Institutional' or 'Professional').
  12. Select 837 file for Claim Acknowledgement (277CA) file review.
  13. Click 'Process' button.
  14. 277CA file content review may also be confirmed directly in system output directory by opening/reviewing file(s).
  15. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all services within claim are accepted by Avatar MSO and including one or more zero-charge claims/services, ensure that Claim level acceptance (2200D Claim Level Status Information) is reported with 'Accepted' status (A2) or 'Split' status (A5).
  16. Examples:
  17. STC*A2:20*20221005*WQ*500~
  18. STC*A5:0*20221005*U*500~
  19. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound zero-charge claims where all or individual services within claim are accepted by Avatar MSO, ensure that Service Line Level Status Information (2220D STC) is included/reported with 'Accepted' or status (A2) for individual accepted zero-charge service lines.
  20. Example:
  21. STC*A2:20**WQ~
  22. Open Crystal Reports or other SQL reporting tool.
  23. In Avatar MSO SQL table 'SYSTEM.svc_status_resp', ensure that claim/service level information is present for processed 837 inbound files; ensure that 'status_cat_code' value = 'A2' or 'A5' for all accepted zero-charge claims/services.
Topics
• 837 Health Care Claim Institutional • Claim Acknowledgement (277CA)
Update 30 Summary | Details
Registry Setting - Send units to Avatar PM
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Registry Settings (MSO)
  • MSO to Parent System Integration Mapping
  • Admission (Outpatient)
  • Financial Eligibility
  • Claim Processing (UB-04)
  • HomeView - 'My Day' view
Scenario 1: MSO To Parent System Integration Mapping - Service Filing
Specific Setup:
  • Registry Setting: Send units to Avatar PM = '1'.
  • MSO to Parent System Integration Mapping:
  • 'File Services On Closing Of batch Or Creation of EOB' = Yes.
  • 'Service Filing' has been used to create an 'Enable Fee Override in PM' record.
  • Select 'Create New' in 'Send Units to Avatar PM'.
  • Enter an 'Effective Date'.
  • Enter an 'End Date'.
  • Select desired values in 'Send Units to Avatar PM'.
  • Click [File].
  • Clients are identified that are eligible for service creation.
  • CPT Codes and Revenue Codes are identified for use in claim processing,



Steps
  1. Open ‘Batch Creation’ and create desired batches.
  2. Use desired ‘Claim Processing (CSM 1500)’, ‘Claim Processing with override (CSM 1500)’, ‘Claim Processing (UB-04) or ‘‘Claim Processing with override (UB-04)’ form to enter and submit the services.
  3. Open 'Close Batch' and close the desired batches.
  4. Open ‘Client Ledger’ to verify that the services were pushed to myAvatar PM.
  5. Create a new batch and a new service that is not the the 'Effective Date' - 'End Date' range.
  6. Open 'Close Batch' and close the desired batch.
  7. Open ‘Client Ledger’ to verify that the services was not pushed to myAvatar PM.
  8. Query the SYSTEM.mso_to_service_failed' table.
  9. Validate that the 'BATCHID' field contains the correct value. Validate that the 'error_message' field contains: Service Not Eligible for Push to PM due to date of service not covered by the service unit override.alidate
  10. If desired, update the 'Enable Fee Override in PM' record and perform additional testing.
  11. If desired, update the ‘Send units to Avatar PM’ registry setting and perform additional testing.
Topics
• MSO To Parent System Integration Mapping • NX
 

Avatar_MSO_2023_Monthly_Release_2023.02.02_Details.csv