Avatar MSO 2023 Quarterly Release 2023.02 Acceptance Tests

• One or more Avatar MSO Contracting Provider entries eligible for Contracting Provider Registration entry/edit
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Contracting Provider Registration' form.
2. Enter/select Contracting Provider for Contracting Provider Registration entry/edit.
3. Click 'Add' button to create new Contracting Provider Registration (or select existing Contracting Provider Registration record for edit).
4. Enter/select values for all required/desired fields in main/first section of 'Contracting Provider Registration' form.
5. Navigate to '837 Defaults' section of form.
6. Ensure 'Require Exact Authorization Number (Institutional)' field is present in 'Contracting Provider Registration' form.
7. Select Yes/No value for 'Require Exact Authorization Number (Institutional)' field (and any other '837 Defaults' section fields as desired).
8. Click 'Submit' button to file 'Contracting Provider Registration' form.
9. Open Avatar MSO 'Contracting Provider Registration' form.
10. Enter/select previously filed Contracting Provider Registration record.
11. Navigate to '837 Defaults' section of form.
12. Ensure that previously selected Yes/No value is present in 'Require Exact Authorization Number (Institutional)' field.
13. Open Crystal Reports or other SQL reporting tool.
14. In Avatar MSO SQL table 'SYSTEM.provider_837_defaults', ensure that 'req_exact_auth_num_inst'/'req_exact_auth_num_type_inst' fields are present and reflect values entered/filed via 'Contracting Provider Registration' form for fields noted above.

• 'Require Exact Authorization Number (Institutional)' must be set to 'Yes' for applicable Contracting Provider Registration
• Client record(s) with and/or without applicable Service Authorization record(s) eligible for inbound 837 Institutional claim/service entry
• 837 Health Care Claim Institutional file with one or more valid claims

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 - in case where one or more claim(s) include an explicit 2300-REF Prior Authorization Number value, ensure that claim/service(s) are assigned this existing Avatar MSO Service Authorization number on compile (regardless of 'Require Exact Authorization Number (Institutional)' field in applicable Contracting Provider Registration).
8. In 837 Institutional Compile Report, where 'Require Exact Authorization Number (Institutional)' is set to 'Yes' for applicable Contracting Provider Registration - in case where one or more claim(s) do not include an explicit 2300-REF Prior Authorization Number value, ensure that claim/service(s) are not assigned to any existing Avatar MSO Service Authorization record by system on compile (and are thus adjudicated with 'Denied' claim status and ''Authorization is blank' explanation of coverage reason).
9. In 837 Institutional Compile Report, where 'Require Exact Authorization Number (Institutional)' is set to 'No' or is not defined for applicable Contracting Provider Registration - in case where one or more claim(s) do not include an explicit 2300-REF Prior Authorization Number value, ensure that claim/service(s) are assigned to existing Avatar MSO Service Authorization record by system on compile where Service Authorization is applicable/available.
10. Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
11. Click 'Process' button.
12. In 837 Institutional Post Report - in case where one or more claim(s) include an explicit 2300-REF Prior Authorization Number value, ensure that claim/service(s) are assigned this existing Avatar MSO Service Authorization number on posting (regardless of 'Require Exact Authorization Number (Institutional)' field in applicable Contracting Provider Registration).
13. In 837 Institutional Post Report, where 'Require Exact Authorization Number (Institutional)' is set to 'Yes' for applicable Contracting Provider Registration - in case where one or more claim(s) do not include an explicit 2300-REF Prior Authorization Number value, ensure that claim/service(s) are not assigned to any existing Avatar MSO Service Authorization record by system on posting (and are thus adjudicated with 'Denied' claim status and ''Authorization is blank' explanation of coverage reason).
14. In 837 Institutional Post Report, where 'Require Exact Authorization Number (Institutional)' is set to 'No' or is not defined for applicable Contracting Provider Registration - in case where one or more claim(s) do not include an explicit 2300-REF Prior Authorization Number value, ensure that claim/service(s) are assigned to existing Avatar MSO Service Authorization record by system on posting where Service Authorization is applicable/available.
15. Open Avatar MSO 'Claim Processing (UB-04)' form.
16. Enter/select claims processing batch created via inbound 837 Institutional file posting.
17. Select 837 Institutional claim for review.
18. Navigate to 'Service Detail' section of form.
19. Select service row for review and click 'Edit Selected Item' button.
20. In case where 837 Institutional claim(s) include an explicit 2300-REF Prior Authorization Number value, ensure that this value is present in 'Authorization Number' field for claim/service.
21. In case where 837 Institutional claim(s) do not include an explicit 2300-REF Prior Authorization Number value, ensure that value is present/not present in 'Authorization Number' field for claim/service as assigned/not assigned by Avatar MSO (according to 'Require Exact Authorization Number (Institutional)' field in applicable Contracting Provider Registration as detailed here).

• Avatar MSO Registry Setting 'Set Batch File Naming Convention' may optionally be configured beyond/in addition to default setting of '1'
• Client record eligible for claim/service entry

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. 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.
8. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
9. For Avatar MSO claims processing batch(es) created via 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form) filing, ensure that Batch Name value is assigned as follows, according to 'Set Batch File Naming Convention' Registry Setting:
10. For default naming convention setting value '1' (Default), ensure that batch name includes 'Fast Service Entry Batch' followed by batch number
11. Batch Name example: 'Fast Service Entry Batch 100'
12. For additional naming convention setting value '2' (Funding Source), ensure that batch name begins with or includes Funding Source name followed by any additional naming convention settings and batch number
13. Registry Setting value examples: '1&2', '2&1'
14. Batch Name examples (respectively): 'Fast Service Entry Batch Medicaid 100', 'Medicaid Fast Service Entry Batch 100'
15. For additional naming convention values including '3' (Claims Received Date), ensure that batch name includes Claims Received Date along with any additional naming convention settings and batch number
16. Registry Setting value examples: '1&2&3', '2&3'
17. Batch Name examples (respectively): 'Fast Service Entry Batch Medicaid 2023-03-28 100', 'Medicaid 2023-03-28 100'
18. For additional naming convention values including '4' (Contracting Provider), ensure that batch name includes Contracting Provider name and ID number followed by any additional convention settings and batch number
19. Registry Setting value examples: '1&2&3&4', '2&4'
20. Batch Name examples (respectively): 'Fast Service Entry Batch Medicaid Horizon House(1) 2023-03-28 100', 'Medicaid Horizon House(1) 100'
21. Note, Contracting Provider Name will only be included in Batch Name value if the batch contains only claims for single Provider

Avatar MSO claims processing batch names may be confirmed via the 'Batch Creation' / 'Close Batch' forms and/or Avatar MSO 'Open Batches' Widget

• Avatar MSO Registry Setting 'Set Batch File Naming Convention' may optionally be configured beyond/in addition to default setting of '1'
• 837 Health Care Claim Professional file with one or more valid claims

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 one or more claims are successfully compiled.
8. Select 'Post File' in the 'Options' field, and select compiled 837 Professional file.
9. Click 'Process' button to post 837 Professional file and create Avatar MSO claims processing batch(es).
10. For Avatar MSO claims processing batch(es) created via 837 Professional claim/service posting, ensure that Batch Name value is assigned as follows, according to 'Set Batch File Naming Convention' Registry Setting:
11. For default naming convention setting value '1' (Default), ensure that batch name includes 'HIPAA837P Claim Processing Batch' followed by batch number
12. Batch Name example: 'HIPAA837P Claim Processing Batch 100'
13. For additional naming convention setting value '2' (Funding Source), ensure that batch name begins with or includes Funding Source name followed by any additional naming convention settings and batch number
14. Registry Setting value examples: '1&2', '2&1'
15. Batch Name examples (respectively): 'HIPAA837P Claim Processing Batch Medicaid 100', 'Medicaid HIPAA837P Claim Processing Batch 100'
16. For additional naming convention values including '3' (Claims Received Date), ensure that batch name includes Claims Received Date along with any additional naming convention settings and batch number
17. Registry Setting value examples: '1&2&3', '2&3'
18. Batch Name examples (respectively): 'HIPAA837P Claim Processing Batch Medicaid 2023-03-28 100', 'Medicaid 2023-03-28 100'
19. For additional naming convention values including '4' (Contracting Provider), ensure that batch name includes Contracting Provider name and ID number followed by any additional convention settings and batch number
20. Registry Setting value examples: '1&2&3&4', '2&4'
21. Batch Name examples (respectively): 'HIPAA837P Claim Processing Batch Medicaid Horizon House(1) 2023-03-28 100', 'Medicaid Horizon House(1) 100'

Avatar MSO claims processing batch names may be confirmed via the 'Batch Creation' / 'Close Batch' forms and/or Avatar MSO 'Open Batches' Widget

• Avatar MSO Registry Setting 'Set Batch File Naming Convention' may optionally be configured beyond/in addition to default setting of '1'
• 837 Health Care Claim Institutional file with one or more valid claims

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 one or more claims are successfully compiled.
8. Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
9. Click 'Process' button to post 837 Institutional file and create Avatar MSO claims processing batch(es).
10. For Avatar MSO claims processing batch(es) created via 837 Institutional claim/service posting, ensure that Batch Name value is assigned as follows, according to 'Set Batch File Naming Convention' Registry Setting:
11. For default naming convention setting value '1' (Default), ensure that batch name includes 'HIPAA837I Claim Processing Batch' followed by batch number
12. Batch Name example: 'HIPAA837I Claim Processing Batch 100'
13. For additional naming convention setting value '2' (Funding Source), ensure that batch name begins with or includes Funding Source name followed by any additional naming convention settings and batch number
14. Registry Setting value examples: '1&2', '2&1'
15. Batch Name examples (respectively): 'HIPAA837I Claim Processing Batch Medicaid 100', 'Medicaid HIPAA837I Claim Processing Batch 100'
16. For additional naming convention values including '3' (Claims Received Date), ensure that batch name includes Claims Received Date along with any additional naming convention settings and batch number
17. Registry Setting value examples: '1&2&3', '2&3'
18. Batch Name examples (respectively): 'HIPAA837I Claim Processing Batch Medicaid 2023-03-28 100', 'Medicaid 2023-03-28 100'
19. For additional naming convention values including '4' (Contracting Provider), ensure that batch name includes Contracting Provider name and ID number followed by any additional convention settings and batch number
20. Registry Setting value examples: '1&2&3&4', '2&4'
21. Batch Name examples (respectively): 'HIPAA837I Claim Processing Batch Medicaid Horizon House(1) 2023-03-28 100', 'Medicaid Horizon House(1) 100'

Avatar MSO claims processing batch names may be confirmed via the 'Batch Creation' / 'Close Batch' forms and/or Avatar MSO 'Open Batches' Widget

1. Open 'Registry Settings' form.
2. Enter search value 'Set Batch File Naming Convention' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Set Batch File Naming Convention' is returned (under 'Avatar MSO-> Claims Processing' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"This registry setting will control how batches will be named when claims were created via 837 files or Fast Service Entry forms. Each setting will have a corresponding numeric value that will dictate what information will be displayed in the Batch name. Those values are

1 - Default - Fast Service Entry Batch + Batch Number or HIPPA837 Claim Processing Batch + Batch Number

2 - Funding Source

3 - Claims Received Date

4 - Contracting Provider - Contracting Provider Name will only be included if the batch contains claims for one Provider

A valid setting can be a combination of the above values separated by an ampersand '&', with no repeating values, ranging from 1 to 4 values (and beginning with 1 or 2). An example of a valid setting is '1&2&3&4'. This setting will result in a Batch Name with 4 distinct values. Setting 1 would be Fast Service Entry Batch for batches created in Fast Service Entry forms, setting 2 would be Funding Source Name, setting 3 would be the Date Claims Received and setting 4 would be the Contracting Provider Name.

Note: Setting must begin with Default value or Funding Source value (setting 1 or 2)."

• One or more EOB(s) existing in system for display

1. Open Avatar MSO 'Provider EOB Report' form (under 'Avatar MSO / MSO Reporting / Provider Management Reports' menu).
2. Ensure 'Contracting Provider' EOB criteria field is required; enter/select Contracting Provider value.
3. In case where Avatar ProviderConnect NX and sub-system codes are used, 'Contracting Provider' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code
4. Ensure 'EOB' dropdown selection field populated with existing EOBs for selected Contracting Provider (including EOB Number, Date, Provider and Amount values in display).
5. Select EOB for Provider EOB Report display.
6. Click 'Launch EOB Report' button to view Provider EOB Report.
7. In Provider EOB Report display, ensure that EOB/Service Remittance Advice information is displayed, including the following information where applicable:
8. EOB Number
9. EOB Amount
10. EOB Date
11. Check Number
12. Check Amount
13. Check Date
14. Provider (including Provider Address information)
15. Client Name / Client ID / Client DOB / Client Gender
16. Date Claim Received
17. Service Remittance Information (including Batch Svc Ref #, Claim #, Auth #, Date of Service, CPT Code, Status, Claimed Amount, Allowed Amount, Denied/Adjusted Amount, Member Co-Pay and Amount Paid information)
18. In Provider EOB Report display for EOB including Adjustment/Retro Claim Adjudication entries, ensure that Adjustment/Retro Claim Adjudication information is displayed, including the following information where applicable:
19. Current Claims
20. Adjustment Total
21. Client Name
22. Adjustment Information (including Batch ID, Svc Ref, Date of Service, Procedure Code, Client ID, Status, Billed Amount, Paid Amount, Adjustment Date, Adjustment Amount, Adjustment Reason)

• One or more 'Pending' status Service Authorization record(s)
• 'Pending Service Authorizations' widget must be assigned to user/home view

1. In myAvatar systems where 'Pending' status service authorization records exist (and are thus included in the Avatar MSO 'Pending Service Authorizations' Widget), ensure that the 'Pending Service Authorization' Widget is correctly rendered and displays authorization information as expected following system login.
2. In case where user does not have access to 'Service Authorization' form, ensure that Authorization Number value for each/all applicable service authorization(s) is displayed/included in the 'Pending Service Authorization' Widget.
3. Where user has access to Avatar MSO 'Service Authorization' form, Authorization Number in Widget display will be linked/may be clicked to open selected authorization record/form; where user does not have access to 'Service Authorization' form, Authorization Number will only be displayed with no action available

• One or more clients with existing Member Service Authorization records
• Avatar MSO 'Service Authorization Information' widget must be assigned to user/home view

1. In myAvatar 'My Clients' Widget, select Client/ID (this will automatically refresh the 'Service Authorization Information' Widget to display Member Service Authorization records/information for selected client).
2. For clients with existing Member Service Authorization record(s), ensure that each/all applicable service authorization(s) are displayed in 'Service Authorization Information' Widget with authorization information.
3. In case where user does not have access to 'Service Authorization' form, ensure that Authorization Number value for each/all applicable service authorization(s) is displayed/included in the 'Service Authorization Information' Widget.
4. Where user has access to Avatar MSO 'Service Authorization' form, Authorization Number in Widget display will be linked/may be clicked to open selected authorization record/form; where user does not have access to 'Service Authorization' form, Authorization Number will only be displayed with no action available

• Avatar MSO Registry Setting 'Display Requested Units Fields' must be enabled
• Authorization CPT/Revenue Code Group(s) must be defined (via Avatar MSO 'Authorization Grouping Definition' form)

1. Open Avatar MSO 'Service Authorization Request' form.
2. Enter/select client for Service Authorization Request entry.
3. Enter/select values for 'Funding Source Authorization Is For', 'Provider To Be Authorized', 'Benefit Plan', 'Begin Date Of Authorization' and 'End Date Of Authorization' fields.
4. Select 'Grouping' in 'Authorization Grouping Or Individual Authorizations' field.
5. Select defined CPT/Revenue Code Group in 'Authorization Grouping' field.
6. Ensure 'Procedure Code Type' and 'Code Authorized' fields are populated with CPT Codes and Revenue Codes as defined for selected Authorization Grouping.
7. Ensure 'Requested Units' and 'Units Authorized' fields are populated with CPT Codes and Revenue Codes as defined for selected Authorization Grouping.
8. Edit/select values for any other 'Service Authorization Request' form fields as required/desired.
9. Click 'Submit' button to file 'Service Authorization Request' form/record.

• One or more loaded, compiled and/or posted inbound 837 Professional format files
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO '837 Health Care Claim Professional' form.
2. Select 'Load File' in the 'Options' field.
3. Enter file path for inbound 837 Professional format file and click 'Process' button.
4. Select 'Compile File', 'Run Report', 'Run Error Report', 'Post File', 'Dump File' or 'Delete Loaded/Compiled File' in the 'Options' field.
5. Enter/select value in 'Contracting Provider' field.
6. In case where Avatar ProviderConnect NX and sub-system codes are used, 'Provider' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code
7. Click the 'Select File' field to expand/display files available for selection.
8. In the 'Select File' field, ensure that only 837 files matched to/identified as selected Contracting Provider's submitter identifier information are displayed and available for selection.
9. If no value is entered/selected for 'Contracting Provider' field, no restriction for Contracting Provider is enforced in 'Select File' field and all files will be available
10. 837 files not matched to/identified as any Contracting Provider in system will not be available where value is entered/selected for 'Contracting Provider' field
11. Enter values for 'Start Date' and/or 'End Date' file selection filter fields in form.
12. Click the 'Select File' field to expand/display files available for selection.
13. In the 'Select File' field, ensure that only 837 files with relevant file date value (date loaded, date compiled, date posted, etc) between 'Start Date' and/or 'End Date' values are displayed and available for selection.
14. If no value is entered for 'Start Date' and/or 'End Date' field, no date restriction for start/end date is enforced in 'Select File' field and all files will be available
15. Select 837 Professional file in 'Select File' field and click 'Process' button to perform action selected in 'Options' field (and any other fields as required/desired for action); ensure process and/or report is completed as expected.
16. Open Crystal Reports or other SQL reporting tool.
17. In Avatar MSO SQL table 'SYSTEM.billing_837_files_by_provider', ensure that data rows are present for all loaded/compiled/posted 837 Professional inbound files, including 'PROVID' value for Contracting Provider identified in 837 file load/compile/post.

• One or more loaded, compiled and/or posted inbound 837 Institutional format files
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO '837 Health Care Claim Institutional' form.
2. Select 'Load File' in the 'Options' field.
3. Enter file path for inbound 837 Institutional format file and click 'Process' button.
4. Select 'Compile File', 'Run Report', 'Run Error Report', 'Post File', 'Dump File' or 'Delete Loaded/Compiled File' in the 'Options' field.
5. Enter/select value in 'Contracting Provider' field.
6. In case where Avatar ProviderConnect NX and sub-system codes are used, 'Provider' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code
7. Click the 'Select File' field to expand/display files available for selection.
8. In the 'Select File' field, ensure that only 837 files matched to/identified as selected Contracting Provider's submitter identifier information are displayed and available for selection.
9. If no value is entered/selected for 'Contracting Provider' field, no restriction for Contracting Provider is enforced in 'Select File' field and all files will be available
10. 837 files not matched to/identified as any Contracting Provider in system will not be available where value is entered/selected for 'Contracting Provider' field
11. Enter values for 'Start Date' and/or 'End Date' file selection filter fields in form.
12. Click the 'Select File' field to expand/display files available for selection.
13. In the 'Select File' field, ensure that only 837 files with relevant file date value (date loaded, date compiled, date posted, etc) between 'Start Date' and/or 'End Date' values are displayed and available for selection.
14. If no value is entered for 'Start Date' and/or 'End Date' field, no date restriction for start/end date is enforced in 'Select File' field and all files will be available
15. Select 837 Institutional file in 'Select File' field and click 'Process' button to perform action selected in 'Options' field (and any other fields as required/desired for action); ensure process and/or report is completed as expected.
16. Open Crystal Reports or other SQL reporting tool.
17. In Avatar MSO SQL table 'SYSTEM.billing_837_files_by_provider', ensure that data rows are present for all loaded/compiled/posted 837 Institutional inbound files, including 'PROVID' value for Contracting Provider identified in 837 file load/compile/post.

• Client record eligible for claim/service entry

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. Enter/select values in all other service detail fields as required/desired.
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).
10. 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.

• Client record with one or more CMS 1500 (Professional) claim(s)/service(s) for adjudication (or eligible for claim/service entry)

1. Open Avatar MSO 'Claim Processing (CMS 1500)' form (and/or 'Claim Processing With Override (CMS 1500)' form).
2. Select claims processing batch for service entry/edit.
3. Open existing claim for adjudication or create new claim for service entry/edit.
4. Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
5. Navigate to 'Service Detail' section of form.
6. Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
7. Ensure that 'Does This Service Represent An Admission' field is not required in form.
8. Enter/select values in all other service detail fields as required/desired.
9. 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)).
10. Click 'Submit' button to file 'Claim Processing (CMS 1500)' form (or 'Claim Processing With Override (CMS 1500)' form) and claim/service(s).

• Client record with one or more UB-04 (Institutional) claim(s)/service(s) for adjudication (or eligible for claim/service entry)

1. Open Avatar MSO 'Claim Processing (UB-04)' form (and/or 'Claim Processing With Override (UB-04)' form).
2. Select claims processing batch for service entry/edit.
3. Open existing claim for adjudication or create new claim for service entry/edit.
4. Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
5. Navigate to 'Service Detail' section of form.
6. Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
7. Ensure that 'Does This Service Represent An Admission' field is not required in form.
8. Enter/select values in all other service detail fields as required/desired.
9. 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)).
10. Click 'Submit' button to file 'Claim Processing (UB-04)' form (or 'Claim Processing With Override (UB-04)' form) and claim/service(s).

• Client record eligible for claim/service entry

1. Open Avatar MSO 'Fast Service Entry Submission' form (under 'Avatar MSO / Claims Processing' menu).
2. In 'Fast Service Entry Submission' form, ensure that 'Close Batches' field is set to 'No' and is read-only/disabled for any system user which does not also have access to Avatar MSO 'Close Batch form (via 'User Definition' and/or 'User Role Definition' forms).
3. Ensure that 'Close Batches' field is set to 'No' by default but value may be changed to 'Yes' for any system user which also has access to Avatar MSO 'Close Batch form (via 'User Definition' and/or 'User Role Definition' forms).
4. Ensure that 'Date Claims Received' field is set to current date by default; ensure that 'Date Claims Received' field is disabled/read-only and date value may not be edited.
5. Navigate to 'Fast Service Detail' section of form.
6. Click 'Add New Item' button to enter new service.
7. Enter/select client for service entry in 'Member Name or ID' field.
8. Ensure that 'Funding Source' field contains only selections applicable to Contracting Provider Registration; enter/select value in 'Funding Source' field.
9. Enter/select value in 'Provider' field.
10. Ensure that 'Performing Provider' field contains only selections applicable to Contracting Provider Registration; select value in 'Performing Provider' field if desired.
11. Enter value in 'Begin Date Of Authorization' and 'End Date Of Authorization' field.
12. Select value in 'Date Of Service' field.
13. Enter/select value in 'Procedure Code' field.
14. Enter value in 'Total Charge' and 'Service Units' field.
15. Enter value in 'Authorization Number' field, or click 'Display Valid Authorizations' button and select Service Authorization applicable to service entry.
16. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO claim/service adjudication rules and requirements.
17. Ensure that 'Claim Status' field is disabled/read-only, and that 'Claim Status' value/status may not be manually edited following entry of service detail values and/or selection of Service Authorization.
18. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
19. Enter/select values in any other fields as required/desired.
20. 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.
21. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es). Claims processing batch(es) created via the 'Fast Service Entry Submission' form where 'Close Batches' field is set to 'No' must be further adjudicated/finalized/closed via Avatar MSO 'Close Batch' form (or 'Close Multiple Batches' form).
22. On return to 'Fast Service Entry Submission' form following service entry/submission/batch creation - ensure that 'Close Batches' field is set to 'No' and is read-only/disabled for any system user which does not also have access to Avatar MSO 'Close Batch form (via 'User Definition' and/or 'User Role Definition' forms).
23. On return to 'Fast Service Entry Submission' form following service entry/submission/batch creation - ensure that 'Close Batches' field is set to 'No' by default but value may be changed to 'Yes' for any system user which also has access to Avatar MSO 'Close Batch form (via 'User Definition' and/or 'User Role Definition' forms).
24. On return to 'Fast Service Entry Submission' form following service entry/submission/batch creation - ensure that 'Date Claims Received' field is set to current date by default; ensure that 'Date Claims Received' field is disabled/read-only and date value may not be edited.

• Client with claim(s)/services eligible for Retro Claim Adjudication entry in Avatar MSO (where no previous 'Void' Retro Claim Adjudication entry has been filed)

1. Open Avatar MSO 'Void Claim Assignment' form (under 'Avatar MSO / Claims Processing' menu).
2. Ensure that the following fields are present in 'Void Claim Assignment' form:
3. 'From Date Of Service'
4. Begin date of service to include for Void service selection; Required
5. 'Through Date Of Service'
6. Begin date of service to include for Void service selection; Required
7. 'Client ID'
8. Client ID for Void service selection; Required
9. 'Contracting Provider'
10. Contracting Provider for Void service selection filtering; Optional
11. 'Contracting Provider Program'
12. Contracting Provider Program for Void service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
13. 'Select Services To Void' button
14. 'File' button
15. Enter value for 'From Date Of Service' and 'Through Date of Service' criteria fields.
16. Ensure that if date span for 'From Date Of Service'/'Through Date of Service' is greater than 365 days, user is presented with an error dialog noting 'Selected Time Period cannot exceed a 365 day period' and the criteria entry is disallowed.
17. Enter/select value for 'Client ID' criteria field.
18. Enter/select value for 'Contracting Provider' criteria field if desired.
19. In case where Avatar ProviderConnect NX and sub-system codes are used, 'Contracting Provider' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code
20. Select value for 'Contracting Provider Program' criteria field if desired.
21. Click 'Select Services To Void' button to display Void service selection dialog for service selection criteria entered.
22. Ensure that 'Select Service(s) To Void' service selection dialog displays all service(s) in 'Closed' status Avatar MSO Claim Processing batch(es) for the selected client/service dates (and 'Contracting Provider'/'Contracting Provider Program' if specified) where no previous 'Void' Retro Claim Adjudication entry has been filed for service.
23. If no eligible services are found for selected client/service dates (and 'Contracting Provider'/'Contracting Provider Program' if specified), ensure that user is presented with error dialog noting 'No Services Found' on clicking 'Select Services To Void' button.
24. In the 'Select Service(s) To Void' dialog, ensure that all service(s) meeting service selection criteria are displayed for selection with the following information for each service:
25. 'Batch'
26. 'Contracting Provider'
27. 'Date Of Service'
28. 'Claim #'
29. 'Procedure Code'
30. 'Charges'
31. 'Total Disbursement'
32. Select one or more service(s) for 'Void' Retro Claim Adjudication entry (using checkbox selection field for each desired service).
33. Click 'OK' button in the 'Select Service(s) To Void' to complete Void service selection.
34. Click 'File' button in 'Void Claim Assignment' form to file 'Void' (full takeback) Retro Claim Adjudication entry for each/all selected service(s).
35. Ensure user is presented with a 'Void Services' confirmation dialog noting 'Selected services will be voided. Continue?'; Click 'Yes' button to proceed with Void Claim Assignment service filing.
36. On Void Claim Assignment filing, ensure user is presented with a confirmation dialog noting 'Filed'; click 'OK' button to close confirmation dialog.
37. Re-enter/re-select values for 'From Date Of Service'/'Through Date of Service' and 'Client ID' Void service selection criteria fields (along with 'Contracting Provider'/'Contracting Provider Program' if desired); Click 'Select Services To Void' button for Void service selection dialog display.
38. Ensure that 'Select Service(s) To Void' service selection dialog excludes any service(s) where previous 'Void' Retro Claim Adjudication entry has been filed for service.

• One or more Service Authorization record(s) for report selection/display

1. Open Avatar MSO 'Authorization Hardcopy' form (under 'Avatar MSO / MSO Reporting / Care Management Reports' menu).
2. Enter/select value in 'Provider' field.
3. In case where Avatar ProviderConnect NX and sub-system codes are used, 'Provider' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code
4. Select value for 'All or Individual Members' (and select Member if 'Individual' selected).
5. Select Service Authorization for Authorization Hardcopy report display in 'Member Authorization' field.
6. Click 'Process Report' button to view Authorization Hardcopy report.
7. In Authorization Hardcopy report display, ensure that Service Authorization information is displayed, including the following information where applicable:
8. Authorization Number
9. Authorization Date Range
10. Provider
11. Member
12. Authorization Grouping:
13. Authorized Group Or Individual
14. Current Authorization Status
15. Current Auth. Status Reason
16. Initial Or Continued Authorization
17. Next Review Date
18. Performing Provider
19. Performing Provider Type
20. Auth Level Care
21. Type Of Authorization
22. Letter Type
23. Level Of Care
24. Primary Diagnosis
25. Secondary Diagnosis
26. Procedure Codes (including Code, Units Authorized, Estimated Liability Code and Totals)
27. Internal Comments
28. Comments On Authorization
29. Financial Eligibility

• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (set to '1','2' or '3')
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• CPT Code/Revenue Code must be selected/included for Fee Override in filing to parent system (via Avatar 'Provider Fee Definition' form)
• One or more 'Approved' status services eligible for filing to parent Avatar PM/Avatar Cal-PM system
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Close Batch' form.
2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
6. Open 'Client Ledger' form in parent Avatar PM system.
7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
8. Select 'Claim/Episode/All Episodes' value.
9. Select 'Ledger Type' value.
10. Click 'Process' button.
11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar PM system following 'Close Batch' filing (where services are valid for filing to parent system).
12. For services originating via Avatar MSO and filed to Avatar PM parent system where Avatar MSO Registry Setting 'Enable Fee Override in PM' is enabled with value '1' - Ensure that 'Cost Of Service' value for service in Avatar PM is set as Avatar MSO 'Total Fee Table Amount' for service.
13. Note - 'Units' value for services originating via Avatar MSO and filed to Avatar PM parent system may be determined/configured via Avatar MSO Registry Setting 'Send Units to Avatar PM'
14. For services originating via Avatar MSO and filed to Avatar PM parent system where Avatar MSO Registry Setting 'Enable Fee Override in PM' is enabled with value '2' - Ensure that 'Cost Of Service' value for service in Avatar PM is set as Avatar MSO 'Expected Disbursement' for service.
15. Note - 'Units' value for services originating via Avatar MSO and filed to Avatar PM parent system may be determined/configured via Avatar MSO Registry Setting 'Send Units to Avatar PM'
16. For services originating via Avatar MSO and filed to Avatar PM parent system where Avatar MSO Registry Setting 'Enable Fee Override in PM' is enabled with value '3' - Ensure that 'Cost Of Service' value for service in Avatar PM is set as Avatar MSO 'Total Charge' for service.
17. Note - 'Units' value for services originating via Avatar MSO and filed to Avatar PM parent system may be determined/configured via Avatar MSO Registry Setting 'Send Units to Avatar PM'
18. Open Crystal Reports or other SQL reporting tool.
19. In Avatar MSO SQL table 'SYSTEM.mso_to_pm_service_failed', ensure that any Avatar MSO 'Approved' status services configured for filing to Avatar PM on 'Close Batch' but not filed due to one or more ineligible restrictions/configurations/missing elements are present in SQL data, including 'error_message' field value noting reason for service not filing to Avatar PM parent system.

• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (set to '4')
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• 'Fee Override in PM' date/override type entry for service date(s) must be defined (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• CPT Code/Revenue Code must be selected/included for Fee Override in filing to parent system (via Avatar 'Provider Fee Definition' form)
• One or more 'Approved' status services eligible for filing to parent Avatar PM/Avatar Cal-PM system
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Close Batch' form.
2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
6. Open 'Client Ledger' form in parent Avatar PM system.
7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
8. Select 'Claim/Episode/All Episodes' value.
9. Select 'Ledger Type' value.
10. Click 'Process' button.
11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar PM system following 'Close Batch' filing (where services are valid for filing to parent system).
12. For services originating via Avatar MSO and filed to Avatar PM parent system where Avatar MSO Registry Setting 'Enable Fee Override in PM' is enabled with value '4' - Ensure that 'Cost Of Service' value for service in Avatar PM is determined by 'Fee Override in PM' date/override type entry applicable to 'Date of Service'.
13. Example:
14. 'Fee Override In PM' entries defined as follows (via 'MSO to Parent System Integration Mapping' form):
15. 'Effective Date' 1/1/2023, 'End Date' 1/31/2023, 'Fee Override in PM' = 'MSO Total Fee Table Amount'
16. 'Effective Date' 2/1/2023, 'End Date' 2/28/2023, 'Fee Override in PM' = 'Expected Disbursement'
17. 'Effective Date' 3/1/2023, 'End Date' 3/31/2023, 'Fee Override in PM' = 'Total Charge'
18. 'Effective Date' 4/1/2023, 'End Date' open/not defined, 'Fee Override in PM' = 'Parent System Service Fee Table'
19. For services originating in Avatar MSO where 'Date of Service' = 1/1/2023 - 1/31/2023, ensure that 'Cost Of Service' value for service in Avatar PM is set as Avatar MSO 'Total Fee Table Amount' for service
20. For services originating in Avatar MSO where 'Date of Service' = 2/1/2023 - 2/28/2023, ensure that 'Cost Of Service' value for service in Avatar PM is set as Avatar MSO 'Expected Disbursement' for service
21. For services originating in Avatar MSO where 'Date of Service' = 3/1/2023 - 3/31/2023, ensure that 'Cost Of Service' value for service in Avatar PM is set as Avatar MSO 'Total Charge' for service
22. For services originating in Avatar MSO where 'Date of Service' = 4/1/2023 or later, ensure that 'Cost Of Service' value for service is set from applicable Avatar PM Service Fee/Cross Reference Maintenance fee entry for service code/date/units/duration/etc.
23. Note - 'Units' value for services originating via Avatar MSO and filed to Avatar PM parent system may be determined/configured via Avatar MSO Registry Setting 'Send Units to Avatar PM'
24. Note - In case where Avatar MSO Registry Setting 'Enable Fee Override In PM' is set to '4' and 'Fee Override in PM' date/override type entries are defined - If Registry Setting 'Enable Fee Override In PM' is subsequently changed to value other than '4', new Registry Setting value will dictate service fee override use/type for services filed to Avatar PM parent system regardless of 'Fee Override in PM' date/override type entries defined
25. Open Crystal Reports or other SQL reporting tool.
26. In Avatar MSO SQL table 'SYSTEM.mso_to_pm_service_failed', ensure that any Avatar MSO 'Approved' status services configured for filing to Avatar PM on 'Close Batch' but not filed due to one or more ineligible restrictions/configurations/missing elements are present in SQL data, including 'error_message' field value noting reason for service not filing to Avatar PM parent system.
27. Note - In case where Avatar MSO 'Approved' status service configured for filing to Avatar PM on 'Close Batch' but not filed due to lack of 'Fee Override in PM' date/override type entry applicable to 'Date of Service' are included with 'error_message' value 'Service Not Eligible for Push to PM due to date of service not covered by the fee override periods'

• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be disabled (set to '0')
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• One or more 'Approved' status services eligible for filing to parent Avatar PM/Avatar Cal-PM system
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Close Batch' form.
2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
6. Open 'Client Ledger' form in parent Avatar PM system.
7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
8. Select 'Claim/Episode/All Episodes' value.
9. Select 'Ledger Type' value.
10. Click 'Process' button.
11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar PM system following 'Close Batch' filing (where services are valid for filing to parent system).
12. For services originating via Avatar MSO and filed to Avatar PM parent system where Avatar MSO Registry Setting 'Enable Fee Override in PM' is disabled - Ensure that 'Cost Of Service' value for service is set from applicable Avatar PM Service Fee/Cross Reference Maintenance fee entry for service code/date/units/duration/etc.
13. Note - 'Units' value for services originating via Avatar MSO and filed to Avatar PM parent system may be determined/configured via Avatar MSO Registry Setting 'Send Units to Avatar PM'
14. Open Crystal Reports or other SQL reporting tool.
15. In Avatar MSO SQL table 'SYSTEM.mso_to_pm_service_failed', ensure that any Avatar MSO 'Approved' status services configured for filing to Avatar PM on 'Close Batch' but not filed due to one or more ineligible restrictions/configurations/missing elements are present in SQL data, including 'error_message' field value noting reason for service not filing to Avatar PM parent system.

1. Open 'Registry Settings' form.
2. Enter search value 'Enable Fee Override In PM' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable Fee Override In PM' is returned (under 'Avatar MSO-> System Maintenance -> Provider Fee Definition Maintenance' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

For this registry setting the allowable values are as follows:

0 - The section 'Fee Override in PM' in 'Provider Fee Definition' form is hidden. When a batch is closed, the Fee associated with each service in the batch being pushed to Avatar PM will be calculated based on the service fee table in Avatar PM.

Updating this registry setting to '0', '1', '2', or '3' will override any effective date range configured when the registry setting was set to '4'.

Selecting '1', '2', '3' or '4' will create an additional section, 'Fee Override in PM', to the 'Provider Fee Definition' form.

1 - When a batch is closed, each service in the batch being pushed to Avatar PM will use the 'Total Fee Table Amount' associated with the service, as the Fee.

2 - When a batch is closed, each service in the batch being pushed to Avatar PM will use the 'Expected Disbursement' associated with the service, as the Fee.

3 - When a batch is closed, each service in the batch being pushed to Avatar PM will use the 'Total Charge' associated with the service, as the Fee.

4 - The 'Service Filing' section in 'MSO To PM System Integration Mapping' form will be updated to include the ability to enable the fee override definition by an effective date range.

Once this setting is set to 4, the fields added to 'Service Filing' sub-section will always remain on the 'MSO to PM System Integration Mapping' form. The options will remain that when a batch is closed either the service fee table in Avatar PM, the 'Total Feel Table Amount', 'Expected Disbursement' amount or 'Total Charge' amount will be utilized as the Fee.

NOTE - The field, 'File Services On Closing Of Batch?', in the form 'MSO to Parent System Integration Mapping' must be set to 'Yes' for services to be filed in Avatar PM when a batch is closed.

• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled/set to '4'
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'MSO To Parent System Integration Mapping' form.
2. Navigate to 'Service Filing' section of form.
3. Ensure sub-section/fields for 'Enable Fee Override In PM' are present in 'Service Filing' section of 'MSO To Parent System Integration Mapping' form (sub-section/fields will be present in form where Avatar MSO Registry Setting 'Enable Fee Override in PM' has ever been enabled with value '4' in system).
4. Ensure the following 'Enable Fee Override In PM' fields are present in form:
5. 'Enable Fee Override In PM'
6. Dropdown selection field, with existing override date/type entries as well as 'Create New' selection
7. 'Effective Date'
8. Begin date for Fee Override Type entry/selection
9. 'End Date'
10. End date for Fee Override Type entry/selection
11. 'Fee Override In PM'
12. Fee override type selection field with the following options:
13. 'MSO Total Fee Table Amount'
14. 'Expected Disbursement'
15. 'Total Charge'
16. 'Parent System Service Fee Table'
17. 'File' Button
18. Select 'Create New' in 'Enable Fee Override In PM' field.
19. Enter value for 'Effective Date' and 'End Date' fields if desired.
20. If no 'End Date' defined, Fee Override Type entry will be considered applicable/effective for all dates on or after 'Effective Date'
21. Select override type to apply to selected dates in the 'Fee Override in PM' field.
22. Click 'File' button to file/save 'Fee Override in PM' date/type entry; ensure user is presented with confirmation dialog noting 'Filed'.
23. On attempting to enter and/or file a 'Fee Override in PM' date/type entry where 'Effective Date'/'End Date' range overlaps one or more existing entries, ensure entry/filing is disallowed and user is presented with an error dialog noting overlap of existing entry (as only one 'Fee Override in PM' date/type entry may exist for any given date/period).
24. Error dialog example: 'The Fee date range for the current Fee Period overlaps an existing entry (04/01/2023 - No End Date)'
25. Select 'Create New' and enter/file additional 'Fee Override in PM' date/type entries as desired.
26. Select existing/previously filed 'Fee Override in PM' date/type entry in 'Enable Fee Override In PM' drop-down field.
27. Ensure values for 'Effective Date', 'End Date' and 'Fee Override in PM' fields are populated/present as previously filed.
28. Open Crystal Reports or other SQL reporting tool.
29. In Avatar MSO SQL table 'SYSTEM.pm_fee_override', ensure that all 'Fee Override in PM' date/type entries filed via 'MSO to Parent System Integration Mapping' form are present in SQL data with field values as entered/filed via form.

• Avatar MSO Registry Setting 'Additional Checking' (837 Professional) must be enabled (Set to '1', '2', '3', '1,2' or '1,3')
• 837 Health Care Claim Professional file with one or more valid claims

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 'Additional Checking' Registry Setting for SSN/DOB value matching is enforced as follows:
8. Where 'Additional Checking' Registry Setting includes value '1' - If social security number in 837 Professional inbound file data (2010BA-REF02) does not match the social security number value in corresponding client/member Avatar demographic record information, ensure that claims/services for member are not successfully compiled (and error returned in Avatar MSO 837 Professional Error Report as in Step 9 below)
9. If social security number in 837 Professional inbound file data (2010BA-REF02) matches the social security number value in corresponding client/member Avatar demographic record information, ensure that claims/services for member are successfully compiled (subject to all other claim/service compilation requirements)
10. Where 'Additional Checking' Registry Setting includes value '2' - If date of birth in 837 Professional inbound file data (2010BA-DMG02) does not match the date of birth value in corresponding client/member Avatar demographic record information for complete/exact year, month and day value, ensure that claims/services for member are not successfully compiled (and error returned in Avatar MSO 837 Professional Error Report as in Step 9 below)
11. If date of birth in 837 Professional inbound file data (2010BA-DMG02) matches the date of birth value in corresponding client/member Avatar demographic record information for complete/exact year, month and day value, ensure that claims/services for member are successfully compiled (subject to all other claim/service compilation requirements)
12. Where 'Additional Checking' Registry Setting includes value '3' - If date of birth in 837 Professional inbound file data (2010BA-DMG02) does not match the date of birth value in corresponding client/member Avatar demographic record information for year and month values, ensure that claims/services for member are not successfully compiled (and error returned in Avatar MSO 837 Professional Error Report as in Step 9 below)
13. If date of birth in 837 Professional inbound file data (2010BA-DMG02) matches the date of birth value in corresponding client/member Avatar demographic record information for year and month values but not for day value, ensure that claims/services for member are successfully compiled (subject to all other claim/service compilation requirements)
14. Select 'Run Error Report' in the 'Options' field, and select compiled 837 Professional file.
15. Click 'Process' button.
16. In 837 Professional Error Report - ensure that 837 Professional client/member information with SSN/DOB values failing the 'Additional Checking' Registry Setting as noted above is included in 837 Professional Error Report as follows:
17. Where 'Additional Checking' Registry Setting SSN check is failed, ensure Error Message 'The social security number contained in the file does not match the social security number on file for member id' is included in report
18. Error Message Example: 'The social security number contained in the file: 111221111 does not match the social security number on file for member id: 999'
19. Where 'Additional Checking' Registry Setting exact/full DOB check is failed, ensure Error Message 'The date of birth contained in the file does not match the date of birth on file for member id' is included in report
20. Error Message Example: 'The date of birth contained in the file: 01/01/88 does not match the date of birth: 02/20/86 on file for member id: 999'
21. Where 'Additional Checking' Registry Setting partial year/month DOB check is failed, ensure Error Message 'The date of birth contained in the file does not match the date of birth on file for member id' is included in report
22. Error Message Example: 'The date of birth contained in the file: 01/88 does not match the date of birth: 11/86 on file for member id: 999'
23. Select 'Post File' in the 'Options' field.
24. Select compiled 837 Professional format file and click 'Process' button.
25. In 837 Professional Post Report and resulting Avatar MSO claim/service data - ensure 'Additional Checking' Registry Setting for SSN/DOB value matching is enforced as detailed above, and that 837 Professional client/member information failing Registry Setting check as noted above is not posted in Avatar MSO (claims/services not created in system).

• Avatar MSO Registry Setting 'Additional Checking' (837 Institutional) must be enabled (Set to '1', '2', '3', '1,2' or '1,3')
• 837 Health Care Claim Institutional file with one or more valid claims

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 'Additional Checking' Registry Setting for SSN/DOB value matching is enforced as follows:
8. Where 'Additional Checking' Registry Setting includes value '1' - If social security number in 837 Institutional inbound file data (2010BA-REF02) does not match the social security number value in corresponding client/member Avatar demographic record information, ensure that claims/services for member are not successfully compiled (and error returned in Avatar MSO 837 Institutional Error Report as in Step 9 below)
9. If social security number in 837 Institutional inbound file data (2010BA-REF02) matches the social security number value in corresponding client/member Avatar demographic record information, ensure that claims/services for member are successfully compiled (subject to all other claim/service compilation requirements)
10. Where 'Additional Checking' Registry Setting includes value '2' - If date of birth in 837 Institutional inbound file data (2010BA-DMG02) does not match the date of birth value in corresponding client/member Avatar demographic record information for complete/exact year, month and day value, ensure that claims/services for member are not successfully compiled (and error returned in Avatar MSO 837 Institutional Error Report as in Step 9 below)
11. If date of birth in 837 Institutional inbound file data (2010BA-DMG02) matches the date of birth value in corresponding client/member Avatar demographic record information for complete/exact year, month and day value, ensure that claims/services for member are successfully compiled (subject to all other claim/service compilation requirements)
12. Where 'Additional Checking' Registry Setting includes value '3' - If date of birth in 837 Institutional inbound file data (2010BA-DMG02) does not match the date of birth value in corresponding client/member Avatar demographic record information for year and month values, ensure that claims/services for member are not successfully compiled (and error returned in Avatar MSO 837 Institutional Error Report as in Step 9 below)
13. If date of birth in 837 Institutional inbound file data (2010BA-DMG02) matches the date of birth value in corresponding client/member Avatar demographic record information for year and month values but not for day value, ensure that claims/services for member are successfully compiled (subject to all other claim/service compilation requirements)
14. Select 'Run Error Report' in the 'Options' field, and select compiled 837 Institutional file.
15. Click 'Process' button.
16. In 837 Institutional Error Report - ensure that 837 Institutional client/member information with SSN/DOB values failing the 'Additional Checking' Registry Setting as noted above is included in 837 Institutional Error Report as follows:
17. Where 'Additional Checking' Registry Setting SSN check is failed, ensure Error Message 'The social security number contained in the file does not match the social security number on file for member id' is included in report
18. Error Message Example: 'The social security number contained in the file: 111221111 does not match the social security number on file for member id: 999'
19. Where 'Additional Checking' Registry Setting exact/full DOB check is failed, ensure Error Message 'The date of birth contained in the file does not match the date of birth on file for member id' is included in report
20. Error Message Example: 'The date of birth contained in the file: 01/01/88 does not match the date of birth: 02/20/86 on file for member id: 999'
21. Where 'Additional Checking' Registry Setting partial year/month DOB check is failed, ensure Error Message 'The date of birth contained in the file does not match the date of birth on file for member id' is included in report
22. Error Message Example: 'The date of birth contained in the file: 01/88 does not match the date of birth: 11/86 on file for member id: 999'
23. Select 'Post File' in the 'Options' field.
24. Select compiled 837 Institutional format file and click 'Process' button.
25. In 837 Institutional Post Report and resulting Avatar MSO claim/service data - ensure 'Additional Checking' Registry Setting for SSN/DOB value matching is enforced as detailed above, and that 837 Institutional client/member information failing Registry Setting check as noted above is not posted in Avatar MSO (claims/services not created in system).

1. Open 'Registry Settings' form.
2. Enter search value 'Additional Checking' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Additional Checking' is returned (under 'Avatar MSO-> Claims Processing -> HIPAA Health Care Claims -> 837 Professional -> Inbound' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

Selecting '1' will verify social security numbers, when processing an 837 Professional file. If the social security number contained in

(2010BA-REF-REF02) does not match the member's social security number in Avatar.

Selecting '2' will verify date of birth, when processing an 837 Professional file. If the date of birth contained in (2010BA-DMG DMG02) does not match the member's date of birth in Avatar.

Selecting '3' will verify only the Month and Year of the subscriber DOB contained in the inbound 837 Professional file matches the Month and Year of the client demographic DOB. If the date of birth contained in (2010BA-DMG-DMG02) does not match the member's date of birth in Avatar.

Selecting '0' will preserve the current verification process, no additional checks, when processing an 837 Professional file.

If multiple checks are desired, add each checks corresponding number separated by a comma.

Example - If the social security number and date of birth checks are desired, the proper format would be "1,2".

1. Open 'Registry Settings' form.
2. Enter search value 'Additional Checking' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Additional Checking' is returned (under 'Avatar MSO-> Claims Processing -> HIPAA Health Care Claims -> 837 Institutional -> Inbound' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

Selecting '1' will verify social security numbers, when processing an 837 Institutional file. If the social security number contained in (2010BA-REF-REF02) does not match the member's social security number in Avatar.

Selecting '2' will verify date of birth, when processing an 837 Institutional file. If the date of birth contained in (2010BA-DMG-DMG02) does not match the member's date of birth in Avatar.

Selecting '3' will verify only the Month and Year of the subscriber DOB contained in the inbound 837 Institutional file matches the Month and Year of the client demographic DOB. If the date of birth contained in (2010BA-DMG-DMG02) does not match the member's date of birth in Avatar.

Selecting '0' will preserve the current verification process, no additional checks, when processing an 837 Institutional file.

If multiple checks are desired, add each checks corresponding number separated by a comma.

Example - If the social security number and date of birth checks are desired, the proper format would be "1,2".