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Avatar MSO 2023 Monthly Release 2023.03.01 Acceptance Tests

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Update 33 Summary | Details
Avatar MSO 'Claims Adjudication Rule Definition'
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Claims Adjudication Rules Definition
  • Fast Service Entry
  • Manual Batch Adjudication
  • Claim Processing (CMS 1500)
  • 837 Health Care Claim Institutional
  • Claim Processing (UB-04)
  • Close Batch
  • 837 Health Care Claim Professional
Scenario 1: Avatar MSO Claim Processing - Verification of 'Claims Adjudication Rule Definition' Limit Function
Specific Setup:
  • One or more Claims Adjudication Rules with 'Limit' entry defined/filed in system applicable to claims/services for adjudication
  • Client with eligible Service Authorization record(s) valid for service entry/claim processing
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO 'Claims Adjudication Rules Definition' form.
  2. Select 'Add' in 'Action' field (or select 'Edit' and select existing rule for review/edit).
  3. Enter/select values for 'Rule ID', 'Rule Description', 'Status', 'Status Reason' and 'Funding Source fields (and 'From Date'/'Through Date' fields if desired).
  4. Select 'Limit' in 'Rule Type' field.
  5. Select/define 'Limit' rule criteria/values using 'The Sum/Total Of', 'Within The Past', 'For The Following Procedure Code' ('Or Procedure Code Group'), 'Must Be', 'The Following Value' and 'For Diagnosis' fields.
  6. Select values for 'For Same Provider' and 'Pay Partial Claim' fields.
  7. Click 'Add Rule' button to save entry for Claims Adjudication Rule 'Limit' entry.
  8. Repeat 'Limit' rule entry/addition as desired.
  9. Click 'Submit' button to file 'Claims Adjudication Rules Definition' form and 'Limit' rule.
  10. Enter one or more claims/services in Avatar MSO using Funding Source and CPT/Revenue Code values where Claims Adjudication Rule 'Limit' entry is defined/applicable for claim processing/adjudication.
  11. Note - Claim/Service entry may be done via 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms, '837 Health Care Claim Professional'/'837 Health Care Claim Institutional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
  12. Adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, nightly automatic adjudication process and/or 'Close Batch' function).
  13. Note - Claims Adjudication Rule functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) with Claim Adjudication Rule(s) applicable claims/services must be adjudicated to reflect rules; Claims Adjudication Rules will not be immediately reflected in Claim Processing forms during initial service entry or in 837 file compilation/posting reports
  14. 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').
  15. Navigate to 'Service Detail' section of form.
  16. Select service row and click 'Edit Selected Item'.
  17. Ensure that in case where service has been adjudicated/status set by Claims Processing Adjudication Rule, upon opening service user is presented with 'Claim Processing...' form alert dialog noting 'This service has been overwritten by 'Claims Adjudication Rules Definition'. Any changes to this service will remove that change until the process is run again.'
  18. Ensure that Claims Adjudication Rules Definition entries are evaluated against claim/service information; in case where service information matches Claim Adjudication 'Limit' rule entry information/criteria and exceeds defined limit for rule (in combination with all other 'Approved' status services existing for client within single/multiple claims and under single/multiple batches), ensure that service is set to 'Denied' or 'Pending' state (per 'Claims Adjudication Rules Definition' form entry).
  19. 'Explanation of Coverage' field will include detail of Claims Adjudication Rule entry failed/exceeded for adjudication
  20. Example: 'The service was denied for the following reason: Claim Status has been set to D because of Claim Adjudication Rule L_99097 - Limit Rule Code 99097'
Topics
• Claims Processing • NX • Claims Adjudication Rule Definition
Update 36 Summary | Details
Registry Setting - Beginning Of Fiscal Year For A Batch
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Registry Settings (PM)
  • Batch Creation
  • Claim Processing (CMS 1500)
  • Claim Processing (UB-04)
  • 837 Health Care Claim Professional
  • 837 Health Care Claim Institutional
  • Claim Processing with Override (CMS 1500)
  • Claim Processing with Override (UB-04)
  • Member Specific Information
  • Batch Creation - Assign ID
Scenario 1: Claim Processing - Registry setting - Beginning Of Fiscal Year For A Batch = 7 (July)
Specific Setup:
  • Registry setting: Beginning Of Fiscal Year For A Batch = desired value. Note the value.
  • Select a Client that is set up to be used in the various Claim Processing form and the 837 Healthcare Claim Institutional or Professional forms.
  • Batch Creation is used to create a new batch that will allow a minimum of two services.
  • An 837 Healthcare Claim Institutional or Professional file exists for loading/compiling/posting.
  • The file contains a minimum of one service in the prior fiscal year and a minimum of one service in the current fiscal year.
  • Note the number of services in the file and the order of the services. For example, the first service in prior fiscal year, second service in current fiscal year, and third service in prior fiscal year. This order will create three batches.
Steps
  1. Open 'Claim Processing (CMS 1500)'.
  2. Select the batch created in 'Setup',
  3. Select the 'Member Name Or ID'.
  4. Select the 'Provider'.
  5. Select the 'Service Detail' section.
  6. Click [Add New Item].
  7. Enter a service date in the previous fiscal year.
  8. Enter service data that will receive an approval.
  9. Click [Add New Item].
  10. Enter a service date in the current fiscal year.
  11. Validate that a message is received stating: The registry 'Beginning Of Fiscal Year For A Batch' is currently enabled and this date of service is not within the fiscal year for this batch.
  12. Click [OK].
  13. Click [Discard].
  14. Click [Yes].
  15. Repeat steps 1-14 for 'Claim Processing with Override (CMS 1500)'.
  16. Repeat steps 1-14 for 'Claim Processing (UB-04)'.
  17. Repeat steps 1-14 for 'Claim Processing with Override (UB-04)'.
  18. Open '837 Health Care Claim Institutional'.
  19. Upload, compile and post the file.
  20. When the posted file report opens validate that a new batch is created for each fiscal year.
  21. Example: Three batches will be created if the order of service is one fiscal year, different fiscal year, and then back to the first fiscal year.
  22. Close the form.
  23. Repeat steps 18 - 21 for '837 Health Care Claim Professional'.
Topics
• 837 Health Care Claim Professional • Claims Processing • 837 Health Care Claim Institutional
 

Avatar_MSO_2023_Monthly_Release_2023.03.01_Details.csv