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Avatar MSO 2023 Monthly Release 2023.04.00 Acceptance Tests

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Update 39 Summary | Details
MSO Approve/Pend/Deny Rule – 837 Health Care Claim Professional
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Guarantors/Payors
  • Program Maintenance
  • Plan Definition
  • Member Specific Information
  • Registry Settings (PM)
  • CPT Code Definition (PM)
  • CPT Code Definition (MSO)
  • Service Fee/Cross Reference Maintenance
  • Funding Source Registration
  • Provider Fee Definition
  • MSO to Parent System Integration Mapping
  • Admission (Outpatient)
  • Diagnosis
  • Financial Eligibility
  • Service Authorization
  • Approve/Pend/Deny Rules Definition
  • Client Charge Input (Charge Fee Access)
  • Client Ledger
  • Create Interim Billing Batch File
  • Electronic Billing
  • Import/Export File Configuration
  • 837 Health Care Claim Professional
  • Crystal Report Viewer
  • Batch Creation - Assign ID
  • Batch Creation
  • Claim Processing (CMS 1500)
  • Manual Batch Adjudication
  • Close Batch
  • Claim Processing with Override (CMS 1500)
Scenario 1: 837 Health Care Claim Professional - Validating Approve/Pend/Deny - Number of Services Per Claim Allowed
Specific Setup:
  • CPT Code Definition (MSO):
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and interactive complexity codes associated in the definition.
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and add-on with the modifier associated in the definition (i.e. 90887:MG).
  • Approve/Pend/Deny Rules Definition:
  • The desired funding sources contains a value of '1' in 'Number of Services Per Claim Allowed' and the desired value in 'Number of Services Per Claim Allowed Exceeded'.
  • Client 1:
  • Is associated to one of the funding sources in the ‘Approve/Pend/Deny Rules Definition’.
  • Service Authorization exists for the MSO CPT Service Codes for the primary code, add-on, and interactive complexity codes.
  • Services have been created for the client where some services are for the primary code only, and some services are for the primacy code with add-on and/or interactive complexity codes.
  • Close Charges has been used to close the charges.
  • Electronic Billing has been used to create claimed services.
  • The Inbound 837 Health Care Claim Professional file(s) have been loaded & compiled. Note the date this occurred.
Steps
  1. Open ‘837 Health Care Claim Professional’.
  2. Select ‘Run Report’ in ‘Options’.
  3. Set the ‘Start Date’ to the date the file was loaded & compiled.
  4. Select the desired file in ‘Select File’.
  5. Click [Process].
  6. Validate that the services in the report are appropriately approved, pended, or denied based on the ‘Approve/Pend/Deny Rules Definition’.
  7. Close the report.
  8. Select ‘Post File’ in ‘Options’.
  9. Set the ‘Start Date’ to the date the file was loaded & compiled.
  10. Select the desired file in ‘Select File’.
  11. Enter data for the required fields.
  12. Click [Process].
  13. Validate that the services in the report are appropriately approved, pended, or denied based on the ‘Approve/Pend/Deny Rules Definition’.
  14. Close the report.
  15. Repeat for additional files.
  16. Close the form.
Scenario 2: Claim Processing (CSM 1500) Validating Approve/Pend/Deny - Number of Services Per Claim Allowed
Specific Setup:
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and interactive complexity codes associated in the definition.
  • Approve/Pend/Deny Rules Definition:
  • The desired fund sources contains a value of '1' in 'Number of Services Per Claim Allowed' and a desired value in 'Number of Services Per Claim Allowed Exceeded'.
  • Client 1:
  • Is associated to one of the funding sources in the 'Approve/Pend/Deny Rules Definition'.
  • Service Authorization exists for the MSO CPT Service Codes for the primary code, add-on, and interactive complexity codes.
  • Batch Creation has been used to create a batch with a value of '1' in 'Total Entries’ and the desired amount‘ in 'Total Charges’. Note the batch number.
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. Enter any desired data in the ‘Claim Processing (CMS 1500)’ section of the form.
  6. Select the ‘Service Detail’ section.
  7. Click [Add New Item].
  8. Enter data in all the required fields for the primary service.
  9. Validate that the ‘Claim Status’ is ‘Approved’.
  10. Click [Add New Item].
  11. Enter data in all the required fields for an add-on and/or interactive complexity.
  12. Validate that the ‘Claim Status’ is ‘Approved’.
  13. Add additional services as needed to meet the amount in 'Total Charges’.
  14. Validate that the ‘Claim Status’ is ‘Approved’.
  15. Click [Submit].
  16. Click [No].
  17. Open ‘Manual Batch Adjudication’.
  18. Select the batch created in setup.
  19. Click [Process].
  20. Click [OK].
  21. Close the form.
  22. Open ‘Close Batch’ and close the batch created in setup.
  23. Open ‘Client Ledger’.
  24. Select the ‘Simple’ report type and desired date range.
  25. Click [Process].
  26. Validate that the services exist.
  27. Close the report.
  28. Close the form.
Claim Processing (CMS 1500) - Create the claim and service details
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Guarantors/Payors
  • Program Maintenance
  • Plan Definition
  • Member Specific Information
  • Registry Settings (PM)
  • CPT Code Definition (PM)
  • CPT Code Definition (MSO)
  • Service Fee/Cross Reference Maintenance
  • Funding Source Registration
  • Provider Fee Definition
  • MSO to Parent System Integration Mapping
  • Admission (Outpatient)
  • Diagnosis
  • Financial Eligibility
  • Service Authorization
  • Approve/Pend/Deny Rules Definition
  • Client Charge Input (Charge Fee Access)
  • Client Ledger
  • Create Interim Billing Batch File
  • Electronic Billing
  • Import/Export File Configuration
  • 837 Health Care Claim Professional
  • Crystal Report Viewer
  • Batch Creation - Assign ID
  • Batch Creation
  • Claim Processing (CMS 1500)
  • Manual Batch Adjudication
  • Close Batch
  • Claim Processing with Override (CMS 1500)
Scenario 1: 837 Health Care Claim Professional - Validating Approve/Pend/Deny - Number of Services Per Claim Allowed
Specific Setup:
  • CPT Code Definition (MSO):
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and interactive complexity codes associated in the definition.
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and add-on with the modifier associated in the definition (i.e. 90887:MG).
  • Approve/Pend/Deny Rules Definition:
  • The desired funding sources contains a value of '1' in 'Number of Services Per Claim Allowed' and the desired value in 'Number of Services Per Claim Allowed Exceeded'.
  • Client 1:
  • Is associated to one of the funding sources in the ‘Approve/Pend/Deny Rules Definition’.
  • Service Authorization exists for the MSO CPT Service Codes for the primary code, add-on, and interactive complexity codes.
  • Services have been created for the client where some services are for the primary code only, and some services are for the primacy code with add-on and/or interactive complexity codes.
  • Close Charges has been used to close the charges.
  • Electronic Billing has been used to create claimed services.
  • The Inbound 837 Health Care Claim Professional file(s) have been loaded & compiled. Note the date this occurred.
Steps
  1. Open ‘837 Health Care Claim Professional’.
  2. Select ‘Run Report’ in ‘Options’.
  3. Set the ‘Start Date’ to the date the file was loaded & compiled.
  4. Select the desired file in ‘Select File’.
  5. Click [Process].
  6. Validate that the services in the report are appropriately approved, pended, or denied based on the ‘Approve/Pend/Deny Rules Definition’.
  7. Close the report.
  8. Select ‘Post File’ in ‘Options’.
  9. Set the ‘Start Date’ to the date the file was loaded & compiled.
  10. Select the desired file in ‘Select File’.
  11. Enter data for the required fields.
  12. Click [Process].
  13. Validate that the services in the report are appropriately approved, pended, or denied based on the ‘Approve/Pend/Deny Rules Definition’.
  14. Close the report.
  15. Repeat for additional files.
  16. Close the form.
Scenario 2: Claim Processing (CSM 1500) Validating Approve/Pend/Deny - Number of Services Per Claim Allowed
Specific Setup:
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and interactive complexity codes associated in the definition.
  • Approve/Pend/Deny Rules Definition:
  • The desired fund sources contains a value of '1' in 'Number of Services Per Claim Allowed' and a desired value in 'Number of Services Per Claim Allowed Exceeded'.
  • Client 1:
  • Is associated to one of the funding sources in the 'Approve/Pend/Deny Rules Definition'.
  • Service Authorization exists for the MSO CPT Service Codes for the primary code, add-on, and interactive complexity codes.
  • Batch Creation has been used to create a batch with a value of '1' in 'Total Entries’ and the desired amount‘ in 'Total Charges’. Note the batch number.
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. Enter any desired data in the ‘Claim Processing (CMS 1500)’ section of the form.
  6. Select the ‘Service Detail’ section.
  7. Click [Add New Item].
  8. Enter data in all the required fields for the primary service.
  9. Validate that the ‘Claim Status’ is ‘Approved’.
  10. Click [Add New Item].
  11. Enter data in all the required fields for an add-on and/or interactive complexity.
  12. Validate that the ‘Claim Status’ is ‘Approved’.
  13. Add additional services as needed to meet the amount in 'Total Charges’.
  14. Validate that the ‘Claim Status’ is ‘Approved’.
  15. Click [Submit].
  16. Click [No].
  17. Open ‘Manual Batch Adjudication’.
  18. Select the batch created in setup.
  19. Click [Process].
  20. Click [OK].
  21. Close the form.
  22. Open ‘Close Batch’ and close the batch created in setup.
  23. Open ‘Client Ledger’.
  24. Select the ‘Simple’ report type and desired date range.
  25. Click [Process].
  26. Validate that the services exist.
  27. Close the report.
  28. Close the form.
Topics
• 837 Health Care Claim Professional • Claims Processing • NX
Update 41 Summary | Details
CPT Code Definition - Import Codes
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • CPT Code Definition (MSO)
Scenario 1: CPT Code Definition - Import Codes - Attach a interactive complexity CPT code to a NON interactive complexity CPT code
Specific Setup:
  • CPT Code Definition (MSO):
  • A valid interactive complexity CPT code is defined in the system. Note the code to be used.
  • An import file is created that contains a record with an invalid interactive complexity CPT code. Note the new code/name/description.
  • An import file is created that contains a record with a valid interactive complexity CPT code. Note the new code/name/description.
Steps
  1. Open Avatar MSO 'CPT Code Definition' form.
  2. Navigate to 'Import Codes' section of form.
  3. Click 'Select Data Import File' button.
  4. Select desired CPT Code Import file.
  5. Click 'Import Codes' button and ensure that 'CPT Code Successfully Filed' dialog is presented.
  6. Navigate to 'CPT Service Code' section of form.
  7. Set 'Add/Edit/Delete CPT Code' field to 'Edit'.
  8. Select recently imported CPT Code defined in processed import file.
  9. Ensure the recently imported CPT code tied to interactive complexity code mentioned in the import file.
  10. Close the form.
  11. Open Avatar MSO 'CPT Code Definition' form.
  12. Navigate to 'Import Codes' section of form.
  13. Click 'Select Data Import File' button.
  14. Select desired CPT Code Import file.
  15. Click [Import Codes].
  16. Ensure that 'The following CPT Codes were skipped: LINE 1: Invalid Interactive Complexity (Interactive Complexity CPT Code not defined.): [CPT CODE entered in the file]' dialog is presented.
  17. Close the form.
Fast Service Entry Submission - Maximum Unites Per day Adjudication rule
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Fast Service Entry Submission
  • Service Authorization
  • Provider Fee Definition
  • Fast Service Entry
  • Approve/Pend/Deny Rules Definition
  • Contracting Provider Registration
  • Fast Service Entry Filing Confirmation
Scenario 1: Duplicate check A/P/D rule functionality without Member ID in the Fast Service Entry form
Specific Setup:
  • Select two existing members with a member authorization for specific CPT Code, Units, and covering a date range including the dates of service to be processed.
  • "Duplicate Service Parameters" field set with "Member ID" unchecked in the 'Approve/Pend/Deny Rules Definition' form for the authorization's funding source.
Steps
  1. Open the 'Fast Service Entry' form.
  2. Add a new service for the 1st member for a specific date of service, CPT code and a member authorization covering the date of service and CPT code specified. Make sure not to select a Performing Provider.
  3. Click [Add New Item].
  4. Verify the previously specified data defaults in.
  5. Verify the "Claim Status" field is set to "Pending" and the Explanation of Coverage field displays the "Over the Maximum Units" message.
  6. Set the "Member name Or ID" field to the name of the 2nd member.
  7. Set the "Authorization Number" field to the authorization number of the 2nd member.
  8. Verify the "Claim Status" field is set to "Approved" and the Explanation of Coverage field is empty.
  9. Close the form.
  10. Open the 'Fast Service Entry Submission' form.
  11. Add a new service for the 1st member for a specific date of service, CPT code and a member authorization covering the date of service and CPT code specified. Make sure not to select a Performing Provider.
  12. Click Add New Item to add a new service.
  13. Verify the previously specified data defaults in.
  14. Verify the "Claim Status" field is set to "Pending" and the Explanation of Coverage field displays the "Over the Maximum Units" message.
  15. Set the "Member name Or ID" field to the name of the 2nd member.
  16. Set the "Authorization Number" field to the authorization number of the 2nd member.
  17. Verify the "Claim Status" field is set to "Approved" and the Explanation of Coverage field is empty.
  18. Submit the form.
  19. Verify the form files successfully.
Claims Processing Override 1500 - Field verification
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Registry Settings (PM)
  • Admission (Outpatient)
  • Financial Eligibility
  • Diagnosis
  • Member Specific Information
  • Service Authorization
  • Provider Fee Definition
  • Fast Service Entry
  • Fast Service Entry Filing Confirmation
  • Claim Processing with Override (CMS 1500)
Scenario 1: 'Claim Processing With Override (CMS 1500)' - Form Verification
Specific Setup:
  • Client record with one or more CMS 1500 (Professional) claim(s)/service(s) for adjudication (or 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 client for service entry in 'Member Name or ID' field.
  6. Ensure that 'Does This Service Represent An Admission' field is not required in form.
  7. Do not select any values in that field.
  8. Enter/select values in all other service detail fields as required/desired.
  9. Verify that the fields 'Expected Disbursement', 'Member Co-Pay' and 'Member Deductible' are enabled for editing.
  10. 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.
  11. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es). Note the batch number.
  12. Ensure that 'Does This Service Represent An Admission' field for entered service row(s) is not required for 'Fast Service Entry' (or 'Fast Service Entry Submission') filing.
  13. Open Avatar MSO 'Claim Processing (CMS 1500)' form (and/or 'Claim Processing With Override (CMS 1500)' form).
  14. Select claims processing batch for service entry/edit.
  15. Open existing claim for adjudication or create new claim for service entry/edit.
  16. Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
  17. Navigate to 'Service Detail' section of form.
  18. Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
  19. Ensure that 'Does This Service Represent An Admission' field is not required in form.
  20. Do not select anything in the ' 'Does This Service Represent An Admission' field.
  21. Enter/select values in all other service detail fields as required/desired.
  22. Verify that the fields 'Expected Disbursement', 'Member Co-Pay' and 'Member Deductible' are enabled for editing.
  23. Click 'Add New Item' button to enter additional service(s) (or select additional existing service and click 'Edit Selected Item' button to update/adjudicate additional service(s)).
  24. Click 'Submit' button to file 'Claim Processing (CMS 1500)' form (or 'Claim Processing With Override (CMS 1500)' form) and claim/service(s).
  25. Verify the form submits successfully.
Fast Service Entry - Explanation Of Coverage
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • CPT Code Definition (MSO)
  • Provider Fee Definition
  • Registry Settings (MSO)
  • Service Authorization
  • Fast Service Entry
  • Authorization Selection - No Authorizations On File Error
  • Performing Provider Association - Error
  • Fast Service Entry Filing Confirmation
  • Admission (Outpatient)
  • Financial Eligibility
  • Diagnosis
  • Member Specific Information
  • Plan Definition
Scenario 1: Fast Service Entry - Validating 'Explanation Of Coverage' message
Specific Setup:
  • Registry Setting:
  • The 'Avatar MSO->Care Management->Service Authorization->->->Enable Service Authorization by Plan' registry setting is set to 'Y'.
  • CPT Code Definition
  • Add a new CPT code. The new CPT code is not covered by the plan. Note the CPT code/description.
  • Provider Fee Definition:
  • New fee definition is defined for this CPT code, member and funding source combination.
  • Plan Definition:
  • This CPT code is not included to any plan definition.
  • Admission:
  • An outpatient client is created, or an existing client is identified. Note the client id/client name.
  • Financial Eligibility:
  • The financial eligibility record is created for the client and an existing guarantor.
  • Diagnosis:
  • An admission diagnosis record is created for the client.
  • Service Authorization:
  • An approved service authorization covering "All" procedure codes is created for the member.
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (under 'Avatar MSO / Claims Processing' menu).
  2. Navigate to 'Fast Service Detail' section of form.
  3. Click 'Add New Item' button to enter new service.
  4. Enter/select client for service entry in 'Member Name or ID' field.
  5. Ensure that 'Funding Source' field contains only selections applicable to Contracting Provider Registration; enter/select value in 'Funding Source' field.
  6. Enter/select value in 'Provider' field.
  7. Ensure that 'Performing Provider' field contains only selections applicable to Contracting Provider Registration; select value in 'Performing Provider' field if desired.
  8. Enter value in 'Begin Date Of Authorization' and 'End Date Of Authorization' field.
  9. Select value in 'Date Of Service' field.
  10. Enter/select value in 'Procedure Code' field.
  11. Enter value in 'Total Charge' and 'Service Units' field.
  12. Enter value in 'Authorization Number' field or click 'Display Valid Authorizations' button.
  13. Verify the message 'No authorizations are on file which match the entered criteria.'.
  14. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with 'Denied'.
  15. Enter the All procedure code authorization number directly.
  16. Notice the denial message is 'Invalid authorization number'.
  17. Close the form.
  18. Open the 'Service Authorization' form.
  19. Add another approved service authorization for the member with desired start/end date.
  20. Cover the desired CPT code for 100 units.
  21. Open the 'Fast Service Entry' form.
  22. Click [Display Valid Authorizations].
  23. Notice that the newly added authorization is loaded for selection correctly.
  24. Delete the authorization number and re-enter the ALL authorization number.
  25. Verify that the service denies with 'Procedure code not found in authorization.'. Please note: This message only be produced if there is another authorization that does cover the CPT code, but a different authorization is entered.
  26. Submit the form.
  27. Verify the claim status and reason stays the same.
SQL Table validation - MSO Authorization Tables
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Crystal Reports or other SQL Reporting tool (MSO Namespace)
Scenario 1: MSO Auth Table validation - SYSTEM.history_member_auths_proc, SYSTEM.service_auth_detail and 'SYSTEM.service_auth_svc' tables
Steps
  1. Open 'Crystal Report' or any other SQL data viewer.
  2. Create the following queries in the MSO namespace:
  3. Query 'SELECT * FROM SYSTEM.history_member_auths_proc'.
  4. Verify the user can retrieved data successfully from the table.
  5. Query 'SELECT * FROM SYSTEM.service_auth_svc'.
  6. Verify the user can retrieved data successfully from the table.
  7. Query 'SELECT * FROM SYSTEM.service_auth_detail'.
  8. Verify the user can retrieved data successfully from the table.
  9. Close the queries.
Topics
• CPT Code Definition • Claims Processing • Database Management
 

Avatar_MSO_2023_Monthly_Release_2023.04.00_Details.csv