Avatar MSO 2023 Quarterly Release 2023.03 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

• CPT Code Definition and/or Revenue Code Definition where dash character ('-') is used in code (Ex: 'H0004-A')

1. Open Avatar MSO 'Claims Adjudication Rules Definition' form.
2. Select 'Add' in 'Action' field (or 'Edit' to select/view/edit existing rule).
3. Enter/select values for Rule Definition fields 'Rule ID', 'Rule Description', 'Status', 'Status Reason', 'Funding Source' (and 'From Date'/'Through Date' if desired).
4. Select 'Limit' in 'Rule Type' field.
5. Enter/select values for Limit Rule Definition fields - selecting CPT Code/Revenue Code where dash character ('-') is used in code (Ex: 'H0004-A') or Procedure Code Group including one or more such codes/characters.
6. Click 'Add Rule' button to save Limit Rule Definition information.
7. Ensure Limit Rule Definition information is displayed in 'Business Rule Viewer' field, including CPT Code/Revenue Code where dash character ('-') is used in code.
8. Click 'Submit' button to file 'Claims Adjudication Rules Definition' form/rule.
9. Ensure confirmation dialog noting 'Claims Adjudication Rules Definition has completed. Do you wish to return to form?' is presented; click 'Yes' button to return to form.
10. Select 'Edit' in 'Action' field and select previously entered/filed 'Limit' Type Claims Adjudication Rule for review.
11. Ensure previously entered/filed Limit Rule Definition information is displayed in 'Business Rule Viewer' field, including CPT Code/Revenue Code where dash character ('-') is used in code.

• Performing Provider Registration record(s) assigned to one or more Contracting Provider Registration

1. Open Avatar MSO 'Performing Provider Registration' form.
2. Click 'New Performing Provider' button to create new Performing Provider Registration (or search/select existing Performing Provider Registration record for edit).
3. Enter/select values in 'Name' and 'Registration Start Date' fields (and 'Registration End Date' if desired).
4. Select one or more values in 'Primary License Type for Claims' field.
5. Select 'Create New' from the 'Primary License Type Effective Dates' field.
6. Enter/select values for 'Effective Start Date', 'Primary License Type for Claims' fields.
7. Click 'File Primary License Type Effective Date' button.
8. Enter/select values for any other Performing Provider Registration fields as required/desired.
9. Click 'Submit' button to file 'Performing Provider Registration' form.
10. Open Avatar MSO 'Contracting Provider Registration' form.
11. Search/select Contracting Provider/Registration record for update/Performing Provider assignment and click 'Edit' button.
12. Navigate to 'Performing Provider's Information' form section.
13. Click 'Add New Item' button to add new Performing Provider assignment row.
14. Search/select Performing Provider Registration filed above.
15. Ensure that 'Effective Start Date' and 'Effective End Date' fields are populated with values filed via 'Performing Provider Registration' form 'Registration Start Date'/'Registration End Date' fields.
16. Click 'Submit' button to file 'Contracting Provider Registration' form with Performing Provider assignment included; repeat as desired for additional Contracting Provider Registration records.
17. Open Avatar MSO 'Performing Provider Registration' form.
18. Enter/select previously filed Performing Provider Registration record currently assigned to one or more Contracting Provider Registrations.
19. Ensure that if 'Registration Start Date' value is updated to date later/more recent than current field value, user is presented with error dialog noting 'Registration Start Date cannot be changed to a later date, registration already associated to a contracting provider' and the entry is disallowed.
20. Note - If Performing Provider is assigned to one or more Contracting Provider Registration records, 'Registration Start Date' may be updated to date earlier than current field date value; 'Registration Start Date' may be updated to date earlier than or later than current field date value only in case where Performing Provider is not assigned to any existing Contracting Provider Registration records,

1. Open Avatar MSO 'Claims Adjudication Rules Definition' form.
2. Select 'Add' in 'Action' field (or 'Edit' to select/view/edit existing rule).
3. Enter/select values for Rule Definition fields 'Rule ID', 'Rule Description', 'Status', 'Status Reason', 'Funding Source' (and 'From Date'/'Through Date' if desired).
4. Select 'Limit' in 'Rule Type' field.
5. Enter/select values for Limit Rule Definition fields - including value for ICD-10 Diagnosis Code in 'For Diagnosis' field (if entering new rule).
6. Click 'Add Rule' button to save Limit Rule Definition information (if entering new rule).
7. Ensure entered/existing Limit Rule Definition information is displayed in 'Business Rule Viewer' field, including 'For Diagnosis' value/code.
8. Click 'Remove Selected Item' button to open rule removal selection dialog.
9. Select Limit Rule Definition row for removal, and click 'OK' button.
10. Ensure Limit Rule Definition is removed from rule and is not displayed in 'Business Rule Viewer' field.

• 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 Automated 837 Health Care Claim Processing must be enabled and configured for system (via Avatar MSO 'Import/Export File Configuration' form)
• Avatar MSO Automated 837 Health Care Claim Processing may optionally be configured to automatically close batch(es) after 837 posting, create Vouchers and/or create EOBs (via Avatar MSO 'Claim Processing Automation' form)
• Inbound 837 Professional and/or Institutional format files for automated processing containing one or more valid claims/services

1. Place multiple 837 Professional and/or Institutional inbound files in 'Processing' directories for Avatar MSO Automated inbound 837 Health Care Claim processing (as defined via 'Import/Export File Configuration' form).
2. Ensure Avatar MSO Automated inbound process for 837 Professional and Institutional files loads/compiles/posts each 837 inbound file in 'Processing' directories (according to behavior defined via 'Import/Export File Configuration' form).
3. Ensure for all Claims Processing batches created via inbound 837 automated processing are closed automatically if configured (as defined in the 'Claim Processing Automation' form). This can be confirmed via 'Close Batch' form, the 'Open Batches' Widget and/or by reviewing data in Avatar MSO SQL table 'SYSTEM.batch_current_data.'
4. Ensure that inbound 837 automated processing completes for all 837 inbound files placed in 'Processing' directories, and that files are correctly moved to 'Processed' directories.
5. Ensure that all posted inbound 837 claims/services are adjudicated (Approved/Denied) following 837 Professional/837 Institutional file posting (according to Avatar MSO adjudication criteria in Approve/Pend/Deny Rules Definition, service requirements, service authorization limits, etc).
6. Ensure that no system errors are recorded in the 'Error' file directory .txt file (as defined in the 'Import/Export File Configuration' form) for processed 837 inbound files.
7. If 999 Functional Acknowledgement response files are configured for generation on 837 file automated processing - ensure that on inbound 837 file processing, 999 Functional Acknowledgement response file(s) are automatically generated on server in directory specified for 999 file creation in the 'Import/Export File Configuration' form.
8. If 277CA Claim Acknowledgement response files are configured for generation on 837 file automated processing - ensure that on inbound 837 file processing, 277CA Claim Acknowledgement response file(s) are automatically generated on server in directory specified for 277CA file creation in the 'Import/Export File Configuration' form.
9. Ensure that Avatar MSO Claim Processing batch(es) are closed following 837 file automated processing (and Vouchers/EOBs created if applicable) as defined in the 'Claim Processing Automation' form.
10. If 835 Health Care Claim Payment/Advice response files are configured for generation on EOB creation - ensure that on EOB creation (manually via 'Create EOB' form or via automated claims processing functionality including scheduled EOB creation), 835 Health Care Claim Acknowledgement response file(s) are automatically generated on server in directory specified for 835 file creation in the 'Claim Processing Automation' form.

• One or more service(s) in closed claims processing batch(es) eligible for Voucher inclusion

1. Open Avatar MSO 'Create Voucher' form.
2. Note - Acceptance testing may also be confirmed in Vouchers created via Avatar MSO Claim Processing Automation functions
3. Select value for 'All or Individual Providers' (and select providers if 'Individual...').
4. Enter value for 'Include Services From' and/or 'Include Services Through' date criteria fields (and any other Voucher creation criteria as desired).
5. Click 'Submit' button to create Voucher for services within defined date range.
6. In Voucher creation confirmation dialog, ensure that values displayed for 'Total Amount of Vouchers Created' and 'Total Number of Vouchers Created' correctly reflect/include all services within 'Include Services From' and 'Include Services Through' date range for EOB(s) included in Voucher.
7. In case where an existing process/form session is already currently filing a Voucher - ensure user is presented with an error dialog noting 'Another Create Voucher process is still running. Please try again later' and the Voucher creation process/'Create Voucher' instance is not completed/filed.

• Avatar MSO Registry Setting 'Specify Adjustment (2110-CAS) Logic' must be enabled (with registry value including '3')
• Avatar MSO Registry Setting 'Include Remark Codes (2110-LQ)' may optionally be enabled/disabled
• The following dictionary codes/data elements must be defined (via Avatar MSO 'Dictionary Update' form):
• 'Other Tabled Files' Data Element '(355) Adjustment Reason Code' (including '(357) Default Remark Code (2110-LQ-02)' Extended Dictionary value if utilizing Remark Codes)
• 'Other Tabled Files' Data Element '(357) Default Remark Code' (if utilizing Remark Codes)
• 'Other Tabled Files' Data Element '(351) Adjustment Code' (including '(354) Adjustment Group Code' / '(355) Adjustment Reason Code' / '(356) Adjustment Group Code 5010' Extended Dictionary values)
• 'Adjustment Code'/'Remark Codes' value must be defined for Approve/Pend/Deny Rule 'Missing valid primary CPT Code' adjudication rule (via Avatar MSO 'MSO EOB Message Customization' form)
• CPT Code(s) defined with 'Add On' CPT Code Category (via Avatar MSO 'CPT Code Definition' form)
• EOB record(s) eligible for 835 outbound file inclusion and including service(s) denied due to 'Missing valid primary CPT Code' adjudication rule

1. Open Avatar MSO '835 Health Care Claim Payment/Advice' form.
2. Note - Acceptance testing may also be confirmed in 835 files created via Avatar MSO Claim Processing Automation functions
3. Select 'Sort File' in the 'Options' field.
4. Select 'Contracting Provider' value.
5. Select EOB(s) for 835 outbound file inclusion in the 'Select EOB(s)' field - selecting EOB including service(s) denied due to 'Missing valid primary CPT Code' adjudication rule.
6. Click 'Process' button.
7. Ensure that in case where one or more EOB(s) including services denied due to 'Missing valid primary CPT Code' adjudication rule are selected for 835 sorting, the 'Process' action completes in timely manner, and that '835 Health Care Claim Payment/Advice Report' is displayed following 835 sorting completion.
8. In '835 Health Care Claim Payment/Advice Report' results, ensure that Adjustment Group Code, Adjustment Reason Code and Remark Code (if utilized) values defined for the 'Missing valid primary CPT Code' adjudication rule are present for services.
9. Close '835 Health Care Claim Payment/Advice Report' report viewer window.
10. Select 'Create File On Server' in the 'Options' field.
11. Select sorted 835 file in the 'Select File (Date - Time - EOB(s))' field.
12. Click 'Process' button.
13. Ensure that 835 Health Care Claim Payment/Advice output file is created on server (in output directory defined via Avatar MSO 'Set System Defaults' form).
14. In 835 Health Care Claim Payment/Advice file created, ensure that Service Adjustment 2110-CAS Claim Adjustment Group Code/Claim Adjustment Reason Code segments/values are present for services denied due to 'Missing valid primary CPT Code' adjudication rule (and related Health Care Remark Code 2110-LQ segments/values if utilized).

1. Open 'Registry Settings' form.
2. Enter search value 'Enable Authorize and Adjudicate on Per Stay Basis' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' is returned (under 'Avatar MSO -> Care Management -> Service Authorization' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

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

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

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Avatar MSO Registry Setting 'Enable Budget Tracking' may be optionally enabled
• One or more client record(s) eligible for Service Authorization entry
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Service Authorization' form.
2. Note - Acceptance testing may also be confirmed via the Avatar MSO 'Budget Tracking Account Setup' form ('Member Service Authorization' section) where 'Enable Budget Tracking' Registry Setting is enabled
3. Select Client ID for 'Service Authorization' entry.
4. Click 'Add' button in 'Service Authorization' form pre-display to enter new record, or select existing row/record and click 'Edit' button to view/update existing record.
5. Enter/select values for 'Funding Source Authorization Is For', 'Benefit Plan', 'Provider To Be Authorized', 'Begin Date Of Authorization', 'End Date Of Authorization' and 'Current Authorization Status' fields.
6. Ensure 'Authorize and Adjudicate on Per Stay Basis' field is present in form, with 'Yes' and 'No' selections available; select 'Yes' value for 'Authorize and Adjudicate on Per Stay Basis' field.
7. Select 'Individual' in the 'Authorization Grouping Or Individual Authorizations' field.
8. Select 'CPT Code' or 'Revenue Code' in the 'Procedure Code Type' field.
9. Enter search term for CPT Code in 'Code Authorized (1)' field; select CPT Code/Revenue Code in 'Code Authorized (1)' field.
10. Enter value '1' in 'Units Authorized (1)' field.
11. Ensure that if any value other than '1' is entered in 'Units Authorized (1)' field, user is presented with error dialog noting 'Units Authorized (1) must be 1 for a Per Stay Authorization' and the entry is disallowed.
12. Ensure that if 'Group' is selected in 'Authorization Grouping Or Individual Authorizations' field, user is presented with error dialog noting 'Authorization Grouping not allowed for a Per Stay Authorization' and the entry is disallowed.
13. Ensure that on attempted entry/selection of 'Code Authorized (2)' values, user is presented with error dialog noting 'Only one procedure code is allowed for a Per Stay Authorization' and the entry is disallowed.
14. Enter/select values for any other fields in form as required/desired.
15. Click 'Submit' button to file 'Service Authorization' form/record.
16. Following 'Service Authorization' form filing, click 'Yes' button in 'Do you want to return to the Pre-Display?' dialog.
17. Select previously entered/updated Service Authorization row in form pre-display and click 'Edit' button to open.
18. Ensure that previously selected/filed value is present in 'Authorize and Adjudicate on Per Stay Basis' field.
19. Open Crystal Reports or other SQL reporting tool.
20. In Avatar MSO SQL table 'SYSTEM.service_auth_detail', ensure that new fields' per_stay_auth_code'/'per_stay_auth_value' are present and reflect value selected/filed for 'Authorize and Adjudicate on Per Stay Basis' field in 'Service Authorization form.
21. In Avatar MSO SQL table 'SYSTEM.service_auth_detail', ensure that new field 'per_stay_svcuniqueidnew' is present; this field will be populated via Avatar MSO Claim Entry/Claim Processing forms/functions with value linking Service Authorization row/record with Claims Processing Batch ID~Service ID attributed to the first/main per-stay approved/paid service for entry once service(s) have been filed.

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Client with eligible Service Authorization record(s) valid for 837 Professional inbound file Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
• 837 Health Care Claim Professional file(s) for compilation/posting including one or more valid claims/services

1. Open Avatar MSO '837 Health Care Claim Professional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Professional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
6. Click 'Process' button.
7. In 837 Professional Compile Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
8. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values will not be immediately reflected in 837 Professional Compile/Post Report information
9. Select 'Post File' in the 'Options' field.
10. Select compiled 837 Professional format file and click 'Process' button.
11. In 837 Professional Post Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
12. Avatar MSO Claim Processing batch(es) created for 837 Professional format claims/services will be adjudicated following file posting (and may also be adjudicated via 'Manual Batch Adjudication' form and/or 'Close Batch' function)
13. Following 837 Professional format inbound file claim/service posting and batch/claim/service adjudication, open claims/services for review via 'Claim Processing (CMS 1500)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
14. Navigate to 'Service Detail' section of form.
15. Select service row and click 'Edit Selected Item'.
16. For 837 Professional/CMS 1500 claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
17. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
18. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
19. Applies to services associated to same/single Service Authorization in same or different 837 Professional files, in same or different claims and/or in same or different Claim Processing batch(es)
20. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
21. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
22. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Client with eligible Service Authorization record(s) valid for 837 Institutional inbound file Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
• 837 Health Care Claim Institutional file(s) for compilation/posting including one or more valid claims/services

1. Open Avatar MSO '837 Health Care Claim Institutional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Institutional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
6. Click 'Process' button.
7. In 837 Institutional Compile Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
8. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values will not be immediately reflected in 837 Institutional Compile/Post Report information
9. Select 'Post File' in the 'Options' field.
10. Select compiled 837 Institutional format file and click 'Process' button.
11. In 837 Institutional Post Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
12. Avatar MSO Claim Processing batch(es) created for 837 Institutional format claims/services will be adjudicated following file posting (and may also be adjudicated via 'Manual Batch Adjudication' form and/or 'Close Batch' function)
13. Following 837 Institutional format inbound file claim/service posting and batch/claim/service adjudication, open claims/services for review via 'Claim Processing (UB-04)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
14. Navigate to 'Service Detail' section of form.
15. Select service row and click 'Edit Selected Item'.
16. For 837 Institutional/UB-04 claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
17. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
18. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
19. Applies to services associated to same/single Service Authorization in same or different 837 Institutional files, in same or different claims and/or in same or different Claim Processing batch(es)
20. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
21. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
22. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• One or more client record(s) eligible for Service Authorization entry/import
• Avatar MSO 'Service Authorization - Member' Import File containing one or more valid import rows where value is defined for 'Authorize and Adjudicate on Per Stay Basis' (field/segment 441)

1. Open 'File Import' form in Avatar Cal-PM.
2. Select File Type '[Avatar MSO] Service Authorization - Member'.
3. Click 'Process Action' button.
4. Select Avatar MSO Service Authorization - Member import file and click 'Open' button.
5. Select 'Compile/Validate File' in 'Action' field.
6. Select loaded import file and click 'Process Action' button.
7. Ensure that 'Compile/Validate File' action completes, and message 'Compiled' or '(File Name) contains one or more errors. These errors can be reviewed using 'Print Errors' action' is displayed.
8. Click 'OK' button.
9. Select 'Post File' in 'Action' field.
10. Select compiled Avatar MSO Service Authorization - Member import file and click 'Process Action' button.
11. Ensure that 'Post' action completes, and message 'Posted' and/or 'The selected file contains one or more lines with compilation errors. Only those lines without compilation errors will be posted' is displayed.
12. Select 'Print Errors' in 'Action' field for compiled import file with one or more errors.
13. Select compiled import file with any errors and click 'Process Action' button.
14. In '[Avatar MSO] Service Authorization - Member' File Import Error report, ensure that all invalid/errored import row(s) where 'Authorize and Adjudicate on Per Stay Basis' is defined as 'Y' and 'Units Authorized' is not defined as '1' or more than one 'Code Authorized' entry exists are included in report with segment/value reference and error message detail.
15. File Import Error examples:
16. 'Units Authorized (1) must be 1 for a Per Stay Authorization'
17. 'Only one procedure code is allowed for a Per Stay Authorization'
18. Open Avatar MSO 'Service Authorization' form.
19. Select Client ID for 'Service Authorization' view/edit where File Import record/row posted.
20. Select Service Authorization row/record filed via File Import in form pre-display and click 'Edit' button to open.
21. Ensure that imported/filed value is present in 'Authorize and Adjudicate on Per Stay Basis' field.

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'

1. Enter two or more claims/services in Avatar MSO, where services are associated to single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
2. Note - Manual claim/service entry may be done via 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms (in addition to 837 inbound file posting)
3. Adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, nightly automatic adjudication process and/or 'Close Batch' function).
4. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values may not be immediately reflected in Claim Processing forms during initial service entry
5. Following batch/claim/service adjudication, open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
6. Navigate to 'Service Detail' section of form.
7. Select service row and click 'Edit Selected Item'.
8. For claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
9. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
10. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
11. Applies to services associated to same/single Service Authorization in same or different claims and/or in same or different Claim Processing batch(es)
12. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
13. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
14. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• One or more services in 'Closed' status Claim Processing batch(es) eligible for Retro Claim Adjudication entry, associated to Service Authorization record(s) where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'

1. Open Avatar MSO 'Retro Claim Adjudication' form.
2. Note - Acceptance testing may also be confirmed via 837 Health Care Claim Professional/Institutional 'Void' and/or 'Replacement' Retro Claim Adjudication entries and/or '[Avatar MSO] Retro Claim Adjudication' File Import
3. Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field.
4. Select 'Claim' and 'Date of Service/Procedure' values for Retro Claim Adjudication entry/update, selecting service which is first service associated to Per-Stay Service Authorization (service which was Approved with 'Expected Disbursement' value from full Provider Fee Definition).
5. On selection of first service associated to Per-Stay Service Authorization, ensure user is presented with an alert dialog noting 'The selected Procedure is the primary Per Stay Procedure. If Updated Approved Units are set to zero then all other procedures in the Stay will be updated to have zero Updated Approved Units also.'
6. Enter zero value for 'Updated Approved Units' and allow system calculation of updated values or directly set 'Take Back Units' and 'Updated Disbursement Amount' values for service (so that Retro Claim Adjudication entry is full service takeback/void entry).
7. Select value for 'Adjustment Code' field if not defaulted automatically.
8. Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
9. On entry/filing of full takeback/void Retro Claim Adjudication for first service associated to Per-Stay Service Authorization - ensure that additional Retro Claim Adjudication entries are automatically created in system for all other Per-Stay services in 'Closed' status batches associated to same Service Authorization, with 'Updated Approved Units' set to zero.
10. Applies to services associated to same/single Service Authorization in same or different claims and/or in same or different Claim Processing batch(es)
11. 'Comments' field for additional/automatically created Retro Claim Adjudication entries will include value 'Included with Per Stay Service.'
12. Retro Claim Adjudication entries created for additional/secondary claims/services associated to Per-Stay Service Authorization may be confirmed via 'Retro Claim Adjudication' form 'Edit' selection (or reviewed directly via Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications')

• Avatar MSO Registry Setting 'Include In EOB Retros For Replaced Services Not On EOB' must be enabled
• Avatar MSO Registry Setting 'Create EOB By Fiscal Year' must be enabled ('MM/DD' Fiscal Year boundary date defined)
• One or more claims/services in 'Closed' status Claims Processing Batch(es), included on Voucher and not yet included on EOB
• One or more 'replacement' Retro Claim Adjudication entries not yet included on an EOB, for claims/services in different Fiscal Year period than claims/services for EOB inclusion above (as defined by 'Create EOB By Fiscal Year' Registry Setting date) and where original services have previously been included in EOB
• Crystal Reports or other SQL tool

1. Open 'Create EOB' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Claims Processing Automation EOB creation
3. Select 'All' or 'Individual Providers' for EOB creation.
4. Click 'Submit' button.
5. Ensure EOB creation confirmation message is displayed on process completion.
6. In EOB creation confirmation message, ensure that 'Total Amount of EOB(s) Created' value reflects/includes sum of all service 'Expected Disbursement' amounts and Retro Claim Adjudication entry/entries 'Take Back Amount' included in EOB(s) generated.
7. In EOB creation confirmation message, ensure that 'Total Number of EOB(s) Created' value reflects total number of EOB(s) created - ensuring that distinct/multiple EOBs are created by Fiscal Year in case where claims/services in Claims Processing Batch(es) and 'replacement claim' Retro Claim Adjudication entries included in EOB creation criteria exist for different Fiscal Year periods (as defined by 'Create EOB By Fiscal Year' Registry Setting date), including Retro Claim Adjudication entries where original services have previously been included in EOB.
8. Open Crystal Reports or other SQL reporting tool.
9. In Avatar MSO SQL table 'SYSTEM.table_eob_core', ensure that distinct/multiple row(s) are present in table for all services and/or Retro Claim Adjudication entries included in EOB creation where distinct/multiple EOBs are created by Fiscal Year, including 'replacement claim' Retro Claim Adjudication entries where original services have previously been included in EOB.
10. In Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications', ensure that 'EOBID' value is updated to newly created EOB number for all Retro Claim Adjudication entries included in EOB(s) including case where original services have previously been included in EOB.

• 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".

• Avatar MSO Registry Setting 'Determine Funding Source By Policy Number' must be enabled
• Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
• Avatar PM Guarantor where 'Validate Guarantor via Avatar Eligibility Tables' is set to 'Yes' (via Avatar PM 'Guarantors/Payors' form)
• 837 Professional claims/services for Avatar MSO Funding Source mapped to PM Guarantor and where 'Validate via Avatar Eligibility Tables' is selected for 'Eligibility Validation Method' (via Avatar MSO 'Funding Source/Guarantor Mapping' form)
• 837 Professional claims/services for Avatar MSO Contracting Provider where 'Eligible Funding Source' field is not defined and/or 'Use Eligible Funding Source to Determine Funding Source for 837 Processing' field is set to 'No' (via Avatar MSO 'Contracting Provider Registration' form)
• Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' for PATID/Subscriber Unique ID)
• 837 Professional format inbound file containing claims/services successfully compiled for Contracting Provider and Member/Client
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO '837 Health Care Claim Professional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Professional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
6. Click 'Process' button.
7. In 837 Professional Compile Report - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client.
8. Note - Avatar MSO Funding Source determined for 837 claims/services will be Funding Source which is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID (in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov') and where Date of Service is covered by eligibility information/Guarantor (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date')
9. Note - If Avatar PM eligibility data for Member/Client does not include Date of Service (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date'), Funding Source for 837 claims/services will not be determined via eligibility information method
10. Note - If no eligibility data exists in Avatar PM for Member/Client, Funding Source for 837 claims/services will not be determined via eligibility information method
11. Note - If more than one Avatar MSO Funding Source is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID, Funding Source for 837 claims/services will not be determined via eligibility information method
12. Select 'Post File' in the 'Options' field.
13. Select compiled 837 Professional format file and click 'Process' button.
14. In 837 Professional Post Report - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client (as detailed above).
15. For any 837 Professional files where Funding Source cannot be determined for one or more Member/Client claims - Select 'Run Error Report' in the 'Options' field.
16. Select compiled/Posted 837 Professional format file and click 'Process' button.
17. In 837 Professional Error Report - ensure that in case where Funding Source cannot be determined for inbound 837 claim/service information, claim/services are not compiled and are listed in 837 Professional Error Report with 'Funding Source not found based on policy number' error condition.
18. 837 Error Message Example: 'Funding Source not found based on policy number: 123456A and service date: 03/01/2023 for member: 123'
19. Open 'Batch Creation' form.
20. Select batch created via 837 Professional inbound file posting.
21. Ensure that 'Funding Source' value for batch is present/same as determined by 837 Professional file compilation/posting.

• Avatar MSO Registry Setting 'Determine Funding Source By Policy Number' must be enabled
• Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
• Avatar PM Guarantor where 'Validate Guarantor via Avatar Eligibility Tables' is set to 'Yes' (via Avatar PM 'Guarantors/Payors' form)
• 837 Professional claims/services for Avatar MSO Funding Source mapped to PM Guarantor and where 'Validate via Avatar Eligibility Tables' is selected for 'Eligibility Validation Method' (via Avatar MSO 'Funding Source/Guarantor Mapping' form)
• 837 Professional claims/services for Avatar MSO Contracting Provider where 'Eligible Funding Source' field is not defined and/or 'Use Eligible Funding Source to Determine Funding Source for 837 Processing' field is set to 'No' (via Avatar MSO 'Contracting Provider Registration' form)
• Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' for PATID/Subscriber Unique ID)
• 837 Institutional format inbound file containing claims/services successfully compiled for Contracting Provider and Member/Client
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO '837 Health Care Claim Institutional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Institutional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
6. Click 'Process' button.
7. In 837 Institutional Compile Report - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client.
8. Note - Avatar MSO Funding Source determined for 837 claims/services will be Funding Source which is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID (in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov') and where Date of Service is covered by eligibility information/Guarantor (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date')
9. Note - If Avatar PM eligibility data for Member/Client does not include Date of Service (compared to eligibility data 'eligibility_eff_date'/'eligibility_exp_date'), Funding Source for 837 claims/services will not be determined via eligibility information method
10. Note - If no eligibility data exists in Avatar PM for Member/Client, Funding Source for 837 claims/services will not be determined via eligibility information method
11. Note - If more than one Avatar MSO Funding Source is mapped to Avatar PM Guarantor where eligibility coverage information exists for Client ID/PATID/Subscriber Unique ID, Funding Source for 837 claims/services will not be determined via eligibility information method
12. Select 'Post File' in the 'Options' field.
13. Select compiled 837 Institutional format file and click 'Process' button.
14. In 837 Institutional Post Report - ensure that in case where inbound 837 claim information matches to Contracting Provider and Member/Client but Funding Source cannot be determined via 'Funding Source' value from Member Specific Information/Member Enrollment/Service Authorization record for Member/Client or 'Eligible Funding Source' value from Contracting Provider Registration, 'Funding Source' value for 837 claims/services is determined from Avatar PM eligibility data for Member/Client (as detailed above).
15. For any 837 Institutional files where Funding Source cannot be determined for one or more Member/Client claims - Select 'Run Error Report' in the 'Options' field.
16. Select compiled/Posted 837 Institutional format file and click 'Process' button.
17. In 837 Institutional Error Report - ensure that in case where Funding Source cannot be determined for inbound 837 claim/service information, claim/services are not compiled and are listed in 837 Institutional Error Report with 'Funding Source not found based on policy number' error condition.
18. 837 Error Message Example: 'Funding Source not found based on policy number: 123456A and service date: 03/01/2023 for member: 123'
19. Open 'Batch Creation' form.
20. Select batch created via 837 Institutional inbound file posting.
21. Ensure that 'Funding Source' value for batch is present/same as determined by 837 Institutional file compilation/posting.

• Avatar Cal-PM Parent System is required for Acceptance Testing with Registry Setting 'Support MSO Other Healthcare Coverage' enabled
• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (set to '1','2', '3' or '4')
• If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• CPT Code/Revenue Code must be selected/included for Fee Override in filing to parent system (via Avatar 'Provider Fee Definition' form)
• One or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information

1. Open Avatar MSO 'Close Batch' form.
2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
6. Open 'Client Ledger' form in parent Avatar Cal-PM system.
7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
8. Select 'Claim/Episode/All Episodes' value.
9. Select 'Ledger Type' value.
10. Click 'Process' button.
11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
12. For services originating via Avatar MSO and filed to Avatar Cal-PM parent system (where Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' and Avatar MSO Registry Setting 'Enable Fee Override in PM' are enabled):
13. Services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM Client Ledger 'Charge' value for service(s) reflects the 'Allowed Amount' value from Avatar MSO Other Healthcare Coverage information for service(s)
14. Note - Avatar Cal-PM 'Cost of Service'/'Guarantor Liability' value for service(s) originating in Avatar MSO with Other Healthcare Coverage information will reflect Client Ledger Charge/Allowed Amount value not including Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM
15. Services not including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM 'Charge'/'Cost Of Service' (as well as 'Guarantor Liability') value for service(s) in Avatar Cal-PM reflects the selected/applicable Avatar MSO Fee Override Type (Expected Disbursement/Fee Table Amount/Total Charge), or PM Service Fee Table Amount where override not selected

• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Plan Definition' form.
2. Search/select existing Benefit Plan for update and click 'OK' button to open, or click 'New Plan' button to enter new Benefit Plan.
3. Enter/select values for fields in 'Plan Definition' main/first section of form as required/desired.
4. Navigate to 'Plan Coverage Definition' section of form.
5. Select existing Plan Covered Services row and click 'Edit Selected Item' button, or click 'Add New Item' button to enter new Plan Covered Services row.
6. Verify 'Plan Coverage Level Name' field is present in form; enter value for 'Plan Coverage Level Name'.
7. Enter/select values for fields in 'Plan Coverage Definition' section of form as required/desired; enter/update additional Plan Covered Services row(s) as desired.
8. Click 'Submit' button to file 'Plan Definition' form/record.
9. Re-open Avatar MSO 'Plan Definition' form.
10. Search/select previously filed/updated Benefit Plan for update and click 'OK' button to open.
11. Navigate to 'Plan Coverage Definition' section of form.
12. Select existing Plan Covered Services row and click 'Edit Selected Item' button.
13. Ensure that previously entered/filed value is present in 'Plan Coverage Level Name' field for selected Plan Covered Services entry/row.
14. Open Crystal Reports or other SQL reporting tool.
15. In Avatar MSO SQL table 'SYSTEM.plan_covered_services', ensure that 'plan_coverage_level_name' field is present and reflects value filed in 'Plan Coverage Level Name' field in 'Plan Definition' form ('Plan Coverage Definition' section).

• Avatar MSO Registry Setting 'Display Requested Units Fields' must be enabled

1. Open Avatar MSO 'Service Authorization Request' form.
2. Enter/select client for Service Authorization Request entry.
3. Enter/select value for 'Funding Source Authorization Is For' field (if value not defaulted in form).
4. In case where user is logged into sub-system code, including use of Avatar ProviderConnect NX - Ensure that the 'Provider To Be Authorized' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code (as defined in 'ProviderConnect NX Defaults' form 'Associated Contracting Providers' field); ensure that the 'Provider To Be Authorized' lookup/selection/entry field is automatically populated with Contracting Provider applicable to/allowed for current sub-system code and disabled/read-only in case where only single 'Associated Contracting Provider' value is defined for sub-system code.
5. Ensure that the 'Contracting Provider Program' field is populated with Contracting Provider Program(s) defined for/applicable to Contracting Provider selected in the 'Provider To Be Authorized' field, including case where 'Provider To Be Authorized' value is defaulted in form; select value in 'Contracting Provider Program' field.
6. Enter/select values for 'Benefit Plan', 'Begin Date Of Authorization' and 'End Date Of Authorization' fields (and any other 'Service Authorization Request' form fields as required/desired).
7. Select value in 'Authorization Grouping Or Individual Authorizations' field (and enter/select one or more CPT/Revenue Codes for authorization if applicable).
8. Click 'Submit' button to file 'Service Authorization Request' form/record.

• 'Maximum Service Information Per Claim Information (Maximum LX Per CLM)' field must be defined for applicable Guarantor/Program Billing Template (via Avatar PM/Cal-PM 'Guarantor/Program Billing Defaults' form)
• Avatar MSO CPT Codes defined with 'Primary Code' / 'Add-On Code' / 'Interactive Complexity' CPT Code Category (via Avatar MSO 'CPT Code Definition' form)
• One or more Avatar MSO originating claims containing 'Approved' status Primary and Add-On/Interactive Complexity service(s) eligible for filing to Avatar Cal-PM on Batch Closing (for outbound 837 Professional file inclusion via Avatar PM/Cal-PM 'Electronic Billing' form)
• Note - Claims/services originating in Avatar MSO for Acceptance Testing must be filed subsequent to installation of Avatar MSO 2023 Update 28

1. In Avatar MSO, create one or more claims containing both 'Approved' status Primary and one or more Add-On/Interactive Complexity service(s) via inbound 837 Health Care Claim Professional posting/filing and/or manual entry (i.e. 'Fast Service Entry' form).
2. Open Avatar MSO 'Close Batch' form.
3. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM/Cal-PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
4. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status Primary and Add-On/Interactive Complexity service(s) in same/single claim eligible for filing to parent Avatar PM/Cal-PM system.
5. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
6. Click 'Submit' button to close batch/file services to parent Avatar PM/Cal-PM system.
7. Open 'Client Ledger' form in parent Avatar PM/Cal-PM system.
8. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
9. Select 'Claim/Episode/All Episodes' value.
10. Select 'Ledger Type' value.
11. Click 'Process' button.
12. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar PM/Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
13. Close 'Client Ledger' form.
14. Close charges for services in Avatar PM/Cal-PM via 'Close Charges' form (and/or Interim Billing Batch forms/functions if desired).
15. Open Avatar PM/Cal-PM 'Electronic Billing' form.
16. Note - Acceptance testing may also be confirmed via Avatar PM/Cal-PM 'Quick Billing' form/functionality
17. Select 837 Professional in 'Billing Form' field.
18. Enter/select 837 file sorting criteria, using values which will include service(s) originating in Avatar MSO with Primary and Add-On/Interactive Complexity service(s) in same/single claim
19. Click 'Process' button to sort/generate 837 Professional file.
20. Select 'Dump File' in the 'Billing Options' field (or select 'Create File On Server' to review output file directly).
21. Select 'Print' in the 'Print Or Delete Report' field.
22. Select 837 Professional file sorted which includes services originating in Avatar MSO, and click 'Process' button to display 837 outbound file data.
23. In Avatar PM/Cal-PM 837 Professional/837 Institutional format outbound electronic billing file data - for services originating via Avatar MSO with Primary and Add-On/Interactive Complexity service(s) in same/single claim, ensure that Primary Service and all related Add-On Service(s)/Interactive Complexity Service(s) are included in same/single claim (multiple 2400-LX service line entries under same/single 2300-CLM iteration), regardless of the value specified in the Guarantor/Program Billing Defaults/Template 'Maximum Service Information Per Claim Information (Maximum LX Per CLM)' field/setting.

• 837 Health Care Claim Institutional file with one or more claims not including 2300 DTP Admission Date loop/segment/value
• Optionally - 837 Health Care Claim Institutional file with one or more claims containing invalid 2300 DTP Admission Date value
• Example: DTP*435*DT*2022101~

1. Open '837 Health Care Claim Institutional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Institutional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
6. Click 'Process' button.
7. In 837 Institutional Compile Report - in case where one or more claim(s) does not include 2300 DTP Admission Date loop/segment/value, ensure that claim/service(s) are successfully compiled (and are included in 837 compile report).
8. In 837 Institutional Compile Report - in case where one or more claim(s) includes an invalid 2300 DTP Admission Date value, ensure that claim/service(s) are not successfully compiled (and are not included in 837 compile report).
9. Select 'Run Error Report' in the 'Options' field, and select compiled 837 Institutional file.
10. In 837 Institutional Error Report - in case where one or more claim(s) include an invalid 2300 DTP Admission Date value, ensure that claim is included in 837 error report with Error Type 'Critical Error' and Error Message 'Invalid admission date for claim.'
11. Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
12. Click 'Process' button.
13. In 837 Institutional Post Report - in case where one or more claim(s) does not include 2300 DTP Admission Date loop/segment/value, ensure that claim/service(s) are successfully posted (and are included in 837 compile report).
14. In 837 Institutional Post Report - in case where one or more claim(s) includes an invalid 2300 DTP Admission Date value, ensure that claim/service(s) are not successfully posted (and are not included in 837 post report).

• File path for 277CA Claim Acknowledgement file creation must be defined in the 'Output Directory' field for system (via Avatar MSO 'Set System Defaults' or 'Import/Export File Configuration' form)
• 277CA Claim Acknowledgment file may optionally be enabled for automatic generation (via Avatar MSO 'Import/Export File Configuration' form)
• 837 Professional and/or Institutional format inbound file(s) for compilation/posting including one or more zero-charge claims/services
• Crystal Reports or other SQL reporting tool

1. Using Avatar MSO '837 Health Care Claim Professional' and/or '837 Health Care Claim Institutional' forms (or via Avatar MSO automated 837 file processing), load/compile/post inbound 837 file(s).
2. Open the Avatar MSO 'Claim Acknowledgement (277CA) File' form.
3. 277CA file generation/content review may also be confirmed directly in system output directory where automatic 277CA file generation is enabled
4. Select 'Create File On Server' in 'Options' field.
5. Select 'Submission Type' field value ('Institutional' or 'Professional').
6. Select 837 file for Claim Acknowledgement (277CA) file creation.
7. Click 'Process' button.
8. Ensure that for selected 837 file, Claim Acknowledgement (277CA) file is created on server in defined directory.
9. This may be confirmed via the 'Claim Acknowledgement (277CA) File' form 'Run Report' or 'Dump File' options, and/or by reviewing files in 277CA output directory
10. Select 'Dump File' in 'Options' field.
11. Select 'Submission Type' field value ('Institutional' or 'Professional').
12. Select 837 file for Claim Acknowledgement (277CA) file review.
13. Click 'Process' button.
14. 277CA file content review may also be confirmed directly in system output directory by opening/reviewing file(s).
15. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all services within claim are accepted by Avatar MSO and including one or more zero-charge claims/services, ensure that Claim level acceptance (2200D Claim Level Status Information) is reported with 'Accepted' status (A2) or 'Split' status (A5).
16. Examples:
17. STC*A2:20*20221005*WQ*500~
18. STC*A5:0*20221005*U*500~
19. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound zero-charge claims where all or individual services within claim are accepted by Avatar MSO, ensure that Service Line Level Status Information (2220D STC) is included/reported with 'Accepted' or status (A2) for individual accepted zero-charge service lines.
20. Example:
21. STC*A2:20**WQ~
22. Open Crystal Reports or other SQL reporting tool.
23. In Avatar MSO SQL table 'SYSTEM.svc_status_resp', ensure that claim/service level information is present for processed 837 inbound files; ensure that 'status_cat_code' value = 'A2' or 'A5' for all accepted zero-charge claims/services.

1. Open 'Registry Settings' form.
2. Enter search value 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' is returned (under 'Avatar MSO -> Claim Processing' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"If 'Y' is selected the 'Set up Co-Pay based on Avatar PM 834' form will be added. PM 834 data will be used to determine the appropriate row in this form to be used to determine the co-pay.

Selecting 'N' removes the form and disables the related functionality."

• Avatar MSO Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' must be enabled
• Note - Avatar PM 2023 Update 58 is required for support of the 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' Registry Setting/functionality
• Avatar MSO Registry Setting 'Enable Private Pay Amount' may optionally be enabled (for use of 'Private Pay Amount' field in lieu of 'Member Co-Pay'/'Member Deductible' fields)
• One or more Claim Status Reason Codes (associated to Claim Adjustment Reason Code) may optionally be defined (for use of 'Other Adjustment' Co-Pay From 834 setup)
• Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
• Avatar PM Guarantor where 'Validate Guarantor via Avatar Eligibility Tables' is set to 'Yes' (via Avatar PM 'Guarantors/Payors' form)
• Claims/Services for Avatar MSO Funding Source mapped to PM Guarantor and where 'Validate via Avatar Eligibility Tables' is selected for 'Eligibility Validation Method' (via Avatar MSO 'Funding Source/Guarantor Mapping' form)
• Claims/services for Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' for PATID/Subscriber Unique ID)
• One or more 'Co-Pay From Avatar PM 834 Setup' entries applicable to Client/Provider/Service Dates/Funding Source/Revenue Codes and 834 Co-Pay Indicator (via Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form)

1. Enter one or more Institutional/UB-04 claims/services in Avatar MSO using Client, Provider, Funding Source and Revenue Code values where 'Co-Pay From Avatar PM 834 Setup' entry is defined/applicable for claim processing/adjudication.
2. Note - Institutional Claim/Service entry using Revenue Codes may be done via 'Claim Processing (UB-04)' forms and '837 Health Care Claim Institutional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
3. Adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, nightly automatic adjudication process and/or 'Close Batch' function).
4. Note - The 'Co-Pay From Avatar PM 834 Setup' claim processing/service co-pay or private pay assignment functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing 'Co-Pay From Avatar PM 834 Setup' applicable claims/services must be adjudicated in order for co-pay/private pay assignment to occur and services to reflect values; 834-determined Co-Pay/Private Pay values will not be immediately reflected in Claim Processing forms during initial service entry or in 837 file compilation/posting reports
5. Following batch/claim/service adjudication - open claims/services for review via 'Claim Processing (UB-04)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
6. Navigate to 'Service Detail' section of form.
7. Select service row and click 'Edit Selected Item'.
8. For Institutional/UB-04 claims/services where applicable Co-Pay/834 Eligibility Assignment entry is defined, ensure that services are assigned 'Member Co-Pay' or 'Private Pay Amount' values as follows:
9. First service within each claim associated to Co-Pay/834 Eligibility Assignment entry is assigned 'Member Co-Pay' or 'Private Pay Amount' from 'How Much Co-Pay to Apply' value defined for service (via Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form/entries and Avatar PM 834 eligibility data)
10. Note - 'Member Co-Pay' or 'Private Pay Amount' assignment is determined by 'Apply as Co-Pay or Private Pay' field in Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form; Co-Pay/834 Eligibility Assignment entries should be defined with Co-Pay or Private Pay selected based on which field present in Avatar MSO Claims Processing forms/according to 'Enable Private Pay Amount' Registry Setting
11. Note - Determination of Co-Pay/834 Eligibility Assignment is via 'Co-Pay Indicator Value' comparison to Avatar PM 834 Eligibility Information Health Coverage (2300-HD) or Health Coverage Policy Number (2300-REF) values in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' ('eligibility_category' or 'reference_identification' fields, respectively)
12. Subsequent/additional services within each claim are not assigned 'Member Co-Pay' or 'Private Pay Amount' (zero amount)
13. Claims/services where no applicable Co-Pay/834 Eligibility Assignment entry is defined are not assigned 'Member Co-Pay' or 'Private Pay Amount' (zero amount)

• Avatar MSO Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form (under 'Avatar MSO / System Maintenance' menu).
2. Note - 'Set Up Co-Pay Based On Avatar PM 834' form is only available where Avatar MSO Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' is enabled
3. Ensure the following fields/items are present in 'Set Up Co-Pay Based On Avatar PM 834' form:
4. 'New Row' / 'Delete Row' buttons
5. 'Rule Name'
6. Name value for Co-Pay/834 Eligibility Assignment entry (required)
7. 'Effective Date'
8. Dictates earliest Date of Service value to apply Co-Pay/834 Eligibility Assignment entry (required)
9. 'Expiration Date'
10. Dictates latest Date of Service value to apply Co-Pay/834 Eligibility Assignment entry (optional)
11. '834 Segment Containing Co-Pay Indicator'
12. Dictates 834 Eligibility Data segment to be compared to 'Co-Pay Indicator Value' to apply Co-Pay/834 Eligibility Assignment entry (required)
13. If '2300-HD-04' is selected, 'Co-Pay Indicator Value' will be compared to Health Coverage (2300-HD) segment values in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' field 'eligibility_category'
14. If '2300-REF-02' is selected, 'Co-Pay Indicator Value' will be compared to Health Coverage Policy Number (2300-REF) segment values in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' field 'reference_identification' (filed where 2300-REF-01 Qualifier = '17 - Client Reporting Category')
15. 'Co-Pay Indicator Value'
16. Dictates 'Co-Pay Indicator Value' for selected 834 Eligibility Data segment to apply Co-Pay/834 Eligibility Assignment entry (required)
17. 'Co-Pay Indicator Location within the Segment'
18. Dictates portion of selected Co-Pay Indicator 834 segment/value to use for 'Co-Pay Indicator Value' comparison (optional)
19. 'Apply as Co-Pay or Private Pay'
20. Dictates whether 'How Much Co-Pay to Apply' value from Co-Pay/834 Eligibility Assignment entry should be filed in 'Member Co-Pay' or 'Private Pay Amount' fields (required)
21. Note - Co-Pay or Private Pay should be selected based on which field present in Avatar MSO Claims Processing forms/according to 'Enable Private Pay Amount' Registry Setting
22. 'Funding Source(s) Co-Pay Applies To' (and 'Current Order' field for entries)
23. Dictates Funding Source(s) to apply Co-Pay/834 Eligibility Assignment entry for (required)
24. Note - Enter search term/click 'Process Search' and select entry to add; multiple Funding Sources may be selected by repeating/adding to 'Current Order' list
25. 'Revenue Code(s) that Trigger Co-Pay' (and 'Current Order' field for entries)
26. Dictates Revenue Code(s) to apply Co-Pay/834 Eligibility Assignment entry for (optional)
27. Note - If no Revenue Codes specified/selected, Co-Pay/834 Eligibility Assignment entry will apply to all Revenue Codes for UB-04/Institutional services
28. Note - Enter search term/click 'Process Search' and select entry to add; multiple Revenue Codes may be selected by repeating/adding to 'Current Order' list
29. 'How Much Co-Pay to Apply'
30. Dictates amount/value to file as Co-Pay/Private Pay Amount for first service in claim where Co-Pay/834 Eligibility Assignment entry applied (required)
31. 'File' button
32. Click 'New Row' button to add Co-Pay/834 Eligibility Assignment entry (or select existing row in grid for view/edit).
33. Enter/select values in all 'Set Up Co-Pay Based On Avatar PM 834' form fields as required/desired.
34. Repeat entry for one or more Co-Pay/834 Eligibility Assignment rows if desired.
35. Click 'File' button to save/file all Co-Pay/834 Eligibility Assignment entries added/updated in form; ensure user is presented with dialog noting 'Filed successfully.'
36. Click 'OK' button to return to 'Set Up Co-Pay Based On Avatar PM 834' form (or optionally close/re-open form).
37. Ensure all previously entered/filed Co-Pay/834 Eligibility Assignment entries are present in form; select one or more rows and confirm field values present as previously entered/filed.
38. Open Crystal Reports or other SQL reporting tool.
39. In Avatar MSO SQL table 'SYSTEM.co_pay_per_pm_834', ensure row(s) are present for all Co-Pay/834 Eligibility Assignment entries filed via 'Set Up Co-Pay Based On Avatar PM 834' form, including field values as entered/selected/filed in form.

• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Contracting Provider(s) eligible for 'Contracting Provider Registration' entry/update
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Contracting Provider Registration' form.
2. Open Avatar MSO 'Contracting Provider Registration' form.
3. Enter/select Contracting Provider for Contracting Provider Registration entry/edit.
4. Click 'Add' button to create new Contracting Provider Registration (or select existing Contracting Provider Registration record for edit).
5. Ensure that 'Medicare Paneled Provider' field is present in form; select value for 'Medicare Paneled Provider'.
6. 'Medicare Paneled Provider' value will dictate whether claims/services for Contracting Provider are subject to the 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rule in claim processing/service adjudication where Avatar PM 'Medicare' Eligibility Coverage COB information is found for client
7. Enter/select values for all other required/desired fields in 'Contracting Provider Registration' form.
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. Ensure that previously selected Yes/No value is present in 'Medicare Paneled Provider' field.
12. Open Crystal Reports or other SQL reporting tool.
13. In Avatar MSO SQL table 'SYSTEM.history_provider_registration', ensure that row is present for information filed via 'Contracting Provider Registration' form, including values for 'medicare_paneled_code' and 'medicare_paneled_value' fields.

• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'CPT Code Definition' form.
2. Select 'Add' or 'Edit' action in 'Add/Edit/Delete CPT Code' field.
3. Enter (or search/select) CPT Code Definition to be added (or updated).
4. Ensure that 'Medicare Allowable Procedure Code' field is present in form; select value for 'Medicare Allowable Procedure Code'.
5. 'Medicare Allowable Procedure Code' value will dictate whether claims/services under selected CPT Code are subject to the 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rule in claim processing/service adjudication where Avatar PM 'Medicare' Eligibility Coverage COB information is found for client
6. Enter/select values for all other required/desired fields in 'CPT Code Definition' form.
7. Click 'File CPT Service Code' button when code entry/edit has been completed.
8. Ensure 'CPT Code Successfully Filed' message dialog is present, and click 'OK' button.
9. Select 'Edit' and open same CPT Service Code record for review.
10. Ensure that previously selected Yes/No value is present in 'Medicare Allowable Procedure Code' field.
11. Open Crystal Reports or other SQL reporting tool.
12. In Avatar MSO SQL table 'SYSTEM.table_cpt_service_codes', ensure that data row is present for information filed via 'Provider Fee Definition' form, including 'medicare_allowable_code' and 'medicare_allowable_value' fields.

• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Approve/Pend/Deny Rules Definition' form.
2. Enter/select Funding Source for Approve/Pend/Deny Rules Definition view/update.
3. Ensure 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' fields are present in form.
4. 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field will dictate how many days prior to 'Date Claim Received' that 'Date of Service' is allowed without Third Party Payment information for service where Avatar PM 'Commercial' and/or 'Medicare' Eligibility Coverage TPL/COB/OHC information is found for client
5. Note - 'Commercial' Eligibility Coverage COB information will be determined by data in Avatar PM Eligibility SQL table SYSTEM.eligibility_dep_cov_cob' where 2320-REF01 Reference Identification Qualifier ('cob_addl_iden_qual') value = '60'(Account Suffix Code) and where 2320-REF02 Reference Identification ('cob_addl_policy_num') value is defined in Avatar MSO Dictionary/Data Element 'TPL Coverage Type Codes - Commercial' ('Other Tabled Files' Indirect, Data Element 90100)
6. Note - 'Medicare' Eligibility Coverage COB information will be determined by data in Avatar PM Eligibility SQL table SYSTEM.eligibility_dep_cov_cob' where 2320-REF01 Reference Identification Qualifier ('cob_addl_iden_qual') value = '60' (Account Suffix Code) and where 2320-REF02 Reference Identification ('cob_addl_policy_num') value is defined in Avatar MSO Dictionary/Data Element 'TPL Coverage Type Codes - Medicare' ('Other Tabled Files' Indirect, Data Element 90101)
7. 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' will dictate claim/service status (Approved/Pended/Denied) in case where 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' allowance is exceeded for claim/services
8. Ensure 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' field is disabled where no value is entered/present in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field.
9. Enter value in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field.
10. Ensure 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' field is enabled and required where value is entered/present in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field.
11. Select value for 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' field.
12. Enter/select values for any other Approve/Pend Deny Rules Definition fields as required/desired.
13. Click 'Submit' button to file 'Approve/Pend/Deny Rules Definition' form.
14. Re-open Avatar MSO 'Approve/Pend/Deny Rules Definition' form, selecting same/previously filed Funding Source for Approve/Pend/Deny Rules Definition view.
15. Ensure values entered/filed for 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' fields are present in form.
16. Open Crystal Reports or other SQL reporting tool.
17. In Avatar MSO SQL table 'SYSTEM.table_app_pen_den_rules', ensure that data row is present for information filed via 'Approve/Pend/Deny Rules Definition' form, including values for 'days_prior_dt_clm_rvd_tpl', 'no_third_party_prim_code' and 'no_third_party_prim_value' fields.

1. Open 'Registry Settings' form.
2. Enter search value 'Enable APD Rule for Missing TPL/COB/OHC' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' is returned (under 'Avatar MSO -> Claims Processing' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"If 'Y' is selected the following will be added:

The 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' fields will be added to the 'Approve/Pend/Deny Rules Definition' form.

The 'Medicare Paneled Provider' field will be added to the 'Contracting Provider Registration' form.

The 'Medicare Allowable Procedure Code' field will be added to the 'CPT Code Definition' form.

Selecting 'N' removes the fields and disables the related functionality."

• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled (with value '2')
• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Note - Avatar PM 2023 Update 58 is required for support of the 'Enable APD Rule for Missing TPL/COB/OHC' Registry Setting/functionality
• Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
• Avatar PM Guarantor where 'Validate Guarantor via Avatar Eligibility Tables' is set to 'Yes' (via Avatar PM 'Guarantors/Payors' form)
• Claims/Services for Avatar MSO Funding Source mapped to PM Guarantor and where 'Validate via Avatar Eligibility Tables' is selected for 'Eligibility Validation Method' (via Avatar MSO 'Funding Source/Guarantor Mapping' form)
• Following Avatar MSO Dictionaries/Data Elements must be defined with values from Avatar PM 834 Eligibility Coverage COB Information, using codes from 'Additional Coordination Of Benefits Identifiers' 2320-REF02 (Reference Identification) where 2320-REF01 (Reference Identification Qualifier) = '60' (Account Suffix Code)
• 'TPL Coverage Type Codes - Commercial' ('Other Tabled Files' Indirect, Data Element 90100)
• 'TPL Coverage Type Codes - Medicare' ('Other Tabled Files' Indirect, Data Element 90101)
• 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' Approve/Pend/Deny Rules must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• Claims/services for Contracting Provider where 'Medicare Paneled Provider' is set to 'Yes' (via Avatar MSO 'Contracting Provider Registration' form)
• Claims/services for CPT Service Code where 'Medicare Allowable Procedure Code' is set to 'Yes' (via Avatar MSO 'CPT Code Definition' form)
• Claims/services for Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL tables 'SYSTEM.eligibility_dependent_cov' and 'SYSTEM.eligibility_dep_cov_cob', for PATID/Subscriber Unique ID)
• Crystal Reports or other SQL reporting tool

1. Enter one or more claims/services in Avatar MSO, using Provider, Funding Source and CPT Code values where Approve/Pend/Deny Rule conditions are defined for claim processing/adjudication.
2. Note - Professional Claim/Service entry using CPT Codes may be done via 'Fast Service Entry'/'Claim Processing (CMS 1500)' forms and '837 Health Care Claim Professional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
3. During or following batch/claim/service entry - 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').
4. Note - If using '837 Health Care Claim Professional' form for 837 compilation/posting, claim processing adjudication status for services may also be reviewed in the 837 Professional Compile/Post report
5. Navigate to 'Service Detail' section of form.
6. Select service row and click 'Edit Selected Item'.
7. For claims/services using Funding Source where 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rule is defined, ensure that claim/service status is adjudicated as follows:
8. Where client has TPL/COB/OHC Eligibility Coverage Information in Avatar PM, 'Commercial' and/or 'Medicare' coverage type will be determined as follows (from information in Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cob' and Avatar MSO 'TPL Coverage Type Codes...' Dictionary Codes):
9. 'Commercial' coverage is determined by Eligibility Coverage Information for Date of Service where Additional Coordination Of Benefits Identifiers 2320-REF01 (Reference Identification Qualifier) = '60' (Account Suffix Code) and 2320-REF02 (Reference Identification) = [Dictionary Code defined for Avatar MSO 'TPL Coverage Type Codes - Commercial' Dictionary]
10. In Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cob', Reference Identification Qualifier = 'cob_addl_iden_qual', Reference Identification = 'cob_addl_policy_num'
11. 'Medicare' coverage is determined by Eligibility Coverage Information for Date of Service where Additional Coordination Of Benefits Identifiers 2320-REF01 (Reference Identification Qualifier) = '60' (Account Suffix Code) and 2320-REF02 (Reference Identification) = [Dictionary Code defined for Avatar MSO 'TPL Coverage Type Codes - Medicare' Dictionary]
12. In Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cob', Reference Identification Qualifier = 'cob_addl_iden_qual', Reference Identification = 'cob_addl_policy_num'
13. For clients determined to have 'Commercial' and/or 'Medicare' TPL/COB/OHC Eligibility Coverage for Date of Service, service must include COB/Third Party Adjudication Information entry to pass the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule
14. Service COB/Third Party Adjudication Information from 837 Professional Other Subscriber Information (2320)/Other Payer Name (2330B)/Line Adjudication Information (2430) loops and/or entered directly in Avatar MSO via 'Enter Third Party Adjudication Data' button in 'Fast Service Entry' and/or 'Claim Processing (CMS 1500)' forms
15. TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny condition applies to services where Date of Service is greater than maximum number of days prior to 'Date Claims Received' value (as defined in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rules field)
16. For services where Date of Service is less than or equal to maximum number of days prior to 'Date Claims Received' value, TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny condition does not apply/is not enforced
17. For clients determined to have 'Commercial' type TPL/COB/OHC Eligibility Coverage, the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is enforced in claim/service adjudication for all Avatar MSO Contracting Providers and all CPT Codes under Funding Source where rule defined
18. For clients determined to have 'Medicare' type TPL/COB/OHC Eligibility Coverage, the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is enforced in claim/service adjudication only for Avatar MSO Contracting Providers and CPT Codes where the following are true:
19. 'Medicare Paneled Provider' field is set to 'Yes' in applicable 'Contracting Provider Registration' entry
20. 'Medicare Allowable Procedure Code' field is set to 'Yes' for 'CPT Code Definition' entry
21. Where either setup field noted above is set to 'No' or not defined, the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is not enforced in claim/service adjudication for clients determined to have 'Medicare' type TPL/COB/OHC Eligibility Coverage
22. Ensure that 'Claim Status' field is set to value selected for 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' Approve/Pend/Deny Rules field for services where TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is enforced and service does not include COB/Third Party Adjudication Information.
23. 'Explanation of Coverage' field will include value 'No COB included with the claim, although primary coverage exists based on 834 eligibility data'

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

"This setting controls the 'Minimum Age', 'Maximum Age' and 'Age on Admission' fields on the 'Provider Fee Definition' form.

The minimum and maximum fields allow users to specify different fees by age range. The 'Age on Admission' field allows the users to specify that the age on the admission date should be used rather than the age on the date of service.

Enter "Y" to have the fields visible on the 'Provider Fee Definition' form. Enter "N" to hide the fields."

• Avatar MSO Registry Setting 'Allow Provider Fee Definition By Age' must be enabled
• Avatar MSO Provider Fee Definition Upload File containing one or more valid rows, including values for 'Minimum Age', 'Maximum Age' and 'Age on Admission' (upload file positions 14, 15 and 27 respectively)

1. Open Avatar MSO 'Provider Fee Definition' form.
2. Navigate to 'Provider Fee Definition Upload' section of form.
3. Click 'Select File' button to open file selection dialog; select Provider Fee Upload File for processing.
4. Click 'Process File Upload' button to process upload file and post/file valid rows.
5. Ensure user is presented with dialog noting Provider Fee Definition Upload file records read/records accepted/records rejected counts; click 'OK button to close dialog.
6. Example: '10 Records Read. 8 Records Accepted. 2 Records Rejected'
7. Navigate to 'Provider Fee Definition' section of form (main/first section).
8. Select 'Edit Existing' in the 'Enter New Or Edit Existing Fee Definition' field.
9. Select Contracting Provider and CPT Service Code/Revenue Code where Provider Fee Definition filed via file upload.
10. Click 'Select Fee Definition To Edit' button and select Provider Fee Definition entry for view.
11. Confirm values filed via upload for Provider Fee Definition entry are present in form, including values for 'Minimum Age', 'Maximum Age' and/or 'Age At Admission' fields (upload file positions 14, 15 and 27 respectively).

• Avatar MSO Registry Setting 'Allow Provider Fee Definition By Age' must be enabled
• CPT Codes/Revenue Codes defined in system for Provider Fee Definition entry
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Provider Fee Definition' form.
2. Select 'Enter New' or 'Edit Existing' action in 'Enter New Or Edit Existing Fee Definition' field.
3. Select Contracting Provider and CPT Service Code/Revenue Code (and select existing fee if using 'Edit Existing' action).
4. Enter value for 'Effective Date' field.
5. Select value for 'Funding Source' field.
6. Ensure the following fields are present in 'CPT Code Definition' form:
7. 'Minimum Age'
8. Dictates client minimum age for Provider Fee to be used/considered (as determined by 'Date of Service' or 'Admission Date' value compared to 'Date of Birth' value for client)
9. 'Maximum Age'
10. Dictates client maximum age for Provider Fee to be used/considered (as determined by 'Date of Service' or 'Admission Date' value compared to 'Date of Birth' value for client)
11. 'Age on Admission'
12. When set to 'No' (or no value selected) - Provider Fee Table entry applicable to service will be determined by client age on the Date of Service (in conjunction with the 'Minimum Age' and 'Maximum Age' Provider Fee Definition criteria fields, as compared to 'Date of Birth' value for client)
13. When set to 'Yes' - Provider Fee Table entry applicable to service will be determined by client age on the Admission Date of associated episode (in conjunction with the 'Minimum Age' and 'Maximum Age' Provider Fee Definition criteria fields, as compared to 'Date of Birth' value for client)
14. Ensure that if value is entered for either 'Minimum Age' or 'Maximum Age', both fields are required.
15. Enter/select values for 'Minimum Age', 'Maximum Age' and 'Age on Admission' fields.
16. Enter/select values for all other Provider Fee Definition fields as desired/required fields.
17. Click 'Submit' button to file Provider Fee Definition record.
18. Ensure user is presented with dialog noting 'Provider Fee Definition has completed. Do you wish to return to form?'; click 'Yes' button to return to form.
19. Select 'Edit Existing' in the 'Enter New Or Edit Existing Fee Definition' field.
20. Select Contracting Provider and CPT Service Code/Revenue Code where Provider Fee Definition previously filed.
21. Click 'Select Fee Definition To Edit' button and select Provider Fee Definition entry for view.
22. Confirm previously entered/filed Provider Fee Definition values are present in form, including values for 'Minimum Age', 'Maximum Age' and/or 'Age At Admission' fields.
23. Open Crystal Reports or other SQL reporting tool.
24. In Avatar MSO SQL table 'SYSTEM.table_prov_fee_byprog', ensure that data row is present for information filed via 'Provider Fee Definition' form, including 'age_min', 'age_max' and ;age_on_admission_code'/'age_on_admission_value' fields.

• Avatar MSO Registry Setting 'Allow Provider Fee Definition By Age' must be enabled
• One or more Provider Fee Definition entries where 'Minimum Age'/'Maximum Age' and 'Age At Admission' are defined
• Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing

1. Enter one or more claims/services in Avatar MSO using Provider, Funding Source and CPT Code/Revenue Code values where Provider Fee Definition entries/rows including 'Minimum Age'/'Maximum Age'/'Age At Admission' are defined in system.
2. 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
3. During or following batch/claim/service entry - 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').
4. Navigate to 'Service Detail' section of form.
5. Select service row and click 'Edit Selected Item'.
6. Ensure 'Total Fee Table Amount' for service(s) is defined by/associated to Provider Fee Definition entries/rows including 'Minimum Age'/'Maximum Age'/'Age At Admission' values as follows:
7. Client Age for service must be equal to or greater than 'Minimum Age' value and equal to or less than 'Maximum Age' value for Provider Fee Definition entry/row to apply to service
8. Where Provider Fee Definition 'Age At Admission' is set to 'No' (or not defined), Client Age for Provider Fee Definition will be determined by 'Date Of Birth' value for client compared to Date of Service
9. Where Provider Fee Definition 'Age At Admission' is set to 'Yes', Client Age for Provider Fee Definition will be determined by 'Date of Birth' value for client compared to Admission Date of associated episode (Client's Age at Admission is used for Provider Fee Definition association regardless of Date of Service)
10. In case where no 'Date of Birth' value is defined for client, Provider Fee Definition entries/rows including 'Minimum Age'/'Maximum Age'/'Age At Admission' values will not be considered/associated to service

• Avatar MSO Registry Setting 'Enable Additional Fields' must be enabled (Avatar MSO -> System Maintenance -> Claim Processing Blackout)
• Following Avatar MSO Dictionaries/Data Elements must be defined:
• 'Blackout Reason' ('Other Tabled Files' Indirect, Data Element 4209)
• 'Blackout Group' ('Other Tabled Files' Indirect, Data Element 4222)
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Claim Processing Blackout' form.
2. Select 'Add' in 'Add/Edit/Delete' field to add new Claim Processing Blackout entry (or select 'Edit' and select existing record for update in 'Blackout Record' field).
3. Where Avatar MSO Registry Setting 'Enable Additional Fields' is enabled, ensure 'Rule ID' and 'Rule Description' fields are present in form (and required).
4. Enter value in 'Rule ID' and 'Rule Description' fields.
5. Where Avatar MSO Registry Setting 'Enable Additional Fields' is enabled, ensure following Claim Processing Blackout criteria/definition fields are present in form:
6. 'Client'
7. 'Provider'
8. 'Funding Sources'
9. Multiple selection format
10. 'Authorization'
11. Populated/available for selection only where value entered/selected in 'Client', 'Provider' or 'Funding Source' field
12. 'Performing Provider'
13. Populated/available for selection only where value entered/selected in 'Provider' field
14. 'Performing Provider Primary License Type'
15. Multiple selection format
16. 'CPT Codes'
17. Multiple selection format
18. 'Revenue Codes'
19. Multiple selection format
20. 'Diagnosis Codes'
21. Multiple selection format
22. 'Blackout Start Date'
23. 'Blackout End Date'
24. 'Authorization Blackout Dates'
25. Multiple selection format; populated with dates covered by 'Authorization' field selection if used
26. 'Claim Status'
27. 'Claim Status Reason'
28. 'Comments'
29. 'Blackout Reason'
30. Populated with selections/values from 'Blackout Reason' Dictionary (Avatar MSO 'Other Tabled Files' Indirect, Data Element 4209)
31. 'Blackout Group'
32. Populated with selections/values from 'Blackout Group' Dictionary (Avatar MSO 'Other Tabled Files' Indirect, Data Element 4222)
33. Used to group Claim Processing Blackout entries for Blackout Group Order Definition
34. Enter/select values in all 'Claim Processing Blackout' form/criteria fields as required/desired.
35. Click 'Submit' button to file Claim Processing Blackout form/record; ensure user is presented with dialog noting 'Claim Processing Blackout has completed. Do you wish to return to form?'
36. Click 'Yes' button to return to 'Claim Processing Blackout' form (or optionally close/re-open form).
37. Select 'Edit' in 'Add/Edit/Delete' field and select previously entered/filed Claim Processing Blackout record in 'Blackout Record' field.
38. Ensure all previously entered/filed Claim Processing Blackout field/criteria entries are present in form.
39. Navigate to 'Blackout Group Order Definition' section of form.
40. Note - If defined, Blackout Group Order will dictate order in which Claim Processing Blackout entries will be checked/performed against claims/services during adjudication (in ascending order according to 'Blackout Group Order' field listing); if Blackout Group Order not defined (or applicable Claim Processing Blackout entry not included in defined Blackout Group/Group Order), Claim Processing Blackout entries will be performed in default order (by ID, using first Claim Processing Blackout entry applicable to service)
41. Select value in 'Blackout Group' field and click 'Add to Order' button to add selected group to 'Blackout Group Order' field/listing
42. Note - 'Place in Order' value may be entered for selected group; doing so will insert in order according to 'Place in Order' value shifting other previous/subsequent entries down/later in order list; if 'Place in Order' value not entered, selected Blackout Group will be added to end of current order
43. Note - Selecting value in 'Blackout Group' field and clicking 'Remove from Order' will remove selected Blackout Group from 'Blackout Group Order' field/listing
44. Repeat Blackout Group selection/order entry as desired.
45. Click 'File Order' button to file/save Blackout Group Order entry/list; ensure user is presented with dialog noting 'Filed successfully.'
46. Click 'OK' button to return to 'Claim Processing Blackout' form, ensuring that previously entered/filed 'Blackout Group Order' list is present in form.
47. Open Crystal Reports or other SQL reporting tool.
48. In Avatar MSO SQL table 'SYSTEM.clm_proc_blackout', ensure row(s) are present for all Claim Processing Blackout entries filed via 'Claim Processing Blackout' form, including values for the following fields: 'rule_id', 'rule_description', 'PPIuniqueid', 'perf_prov_license_code', 'perf_prov_license_shvalue', 'perf_prov_license_value', 'cpt_codes', 'revenue_codes', 'diagnosis_codes', 'funding_sources', 'blackout_group_code' and 'blackout_group_code'.
49. In Avatar MSO SQL table 'SYSTEM.blackout_group_order', ensure that row(s) are present for all Blackout Groups included in 'Blackout Group Order' list entered/filed via 'Claim Processing Blackout' form with 'order' field value.

1. Open 'Registry Settings' form.
2. Enter search value 'Enable Additional Fields' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable Additional Fields' is returned (under 'Avatar MSO -> System Maintenance -> Claim Processing Blackout' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"If 'Y' is selected the following fields are added to the 'Claim Processing Blackout' form:

'Rule ID'

'Rule Description'

'Performing

Provider'

'Performing Provider Primary License Type'

'CPT Codes'

'Revenue

Codes'

'Diagnosis Codes'

'Funding Sources' (enables selection of multiple Funding Sources)

The 'Blackout Group Order Definition' section

NOTE: This registry setting is a ONE WAY registry setting that can only be enabled. Once turned on, this registry setting cannot be disabled."

• Avatar MSO Registry Setting 'Enable Additional Fields' must be enabled (Avatar MSO -> System Maintenance -> Claim Processing Blackout)
• One or more Claim Processing Blackout entries applicable to Client/Provider/Service Dates/Funding Source/CPT or Revenue Codes/Diagnosis Codes must be defined (via Avatar MSO 'Claim Processing Blackout' form)
• Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing
• Crystal Reports or other SQL reporting tool

1. Enter one or more claims/services in Avatar MSO using Provider, Funding Source, CPT/Revenue Codes and Diagnosis Code values where 'Claim Processing Blackout' entry is defined/applicable for claim processing/adjudication.
2. 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
3. During or following batch/claim/service entry - 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').
4. Navigate to 'Service Detail' section of form.
5. Select service row and click 'Edit Selected Item'.
6. Ensure that Claim Processing Blackout entries are evaluated against claim/service information; in case where service information matches Claim Processing Blackout entry information/criteria, ensure that service is set to 'Denied' or 'Pending' state (per 'Claim Processing Blackout' form definition).
7. Claim Processing Blackout entries/services will be evaluated on the following claim/service criteria fields where defined in Claim Processing Blackout entry (with Avatar MSO Registry Setting 'Enable Additional Fields' enabled):
8. Client
9. Provider
10. Funding Source
11. Authorization
12. Performing Provider
13. Performing Provider Primary License Type
14. CPT Codes
15. Revenue Code
16. Diagnosis Code
17. Blackout Start Date (compared to Date of Service)
18. Blackout End Date (compared to Date of Service)
19. Authorization Blackout Dates (compared to Date of Service)
20. Claim Processing Blackout entries will be evaluated against services in order defined by 'Blackout Group Order Definition' if defined (via 'Claim Processing Blackout' form definition); if Blackout Group Order not defined (or applicable Claim Processing Blackout entry not included in defined Blackout Group/Group Order), Claim Processing Blackout entries will be performed in default order (by ID, using first Claim Processing Blackout entry applicable to service)
21. For claims/services where applicable Claim Processing Blackout entry is defined - ensure that 'Claim Status' field is set to value selected for Claim Processing Blackout 'Claim Status' field ('Denied' or 'Pending'); ensure 'Claim Status Reason' field is set to value selected for Claim Processing Blackout 'Claim Status Reason' field.
22. 'Explanation of Coverage' field will include value 'This service occurs during a claim processing blackout'
23. Example: 'The service was denied for the following reason: This service occurs during a claim processing blackout.'
24. In Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail', field 'blackout_id' will reflect Claim Processing Blackout entry applied to service row (linked to 'SYSTEM.clm_proc_blackout.ID')

• Client record(s) eligible for Service Authorization entry/filing
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Service Authorization' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO 'Service Authorization Request' form
3. Select Client ID for 'Service Authorization' entry.
4. Click 'Add' button in 'Service Authorization' form pre-display to enter new record, or select existing row/record and click 'Edit' button to view/update existing record.
5. Enter/select values for 'Funding Source Authorization Is For', 'Benefit Plan', 'Provider To Be Authorized', 'Begin Date Of Authorization', 'End Date Of Authorization' and 'Current Authorization Status' fields (and any other 'Service Authorization' form fields as required/desired).
6. Select value in 'Authorization Grouping Or Individual Authorizations' field (and enter/select one or more CPT/Revenue Codes for authorization if applicable).
7. Click 'Submit' button to file 'Service Authorization' form/record.
8. Open Crystal Reports or other SQL reporting tool.
9. In Avatar MSO SQL table 'SYSTEM.service_auth_detail', ensure that row is filed/present in table for Service Authorization record, including user name information/values in fields 'data_entry_by', 'data_entry_user_name' and 'original_data_entry_person' (truncated to 50 characters if user name description exceeds this length).