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Avatar MSO 2023 Update 13

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Product Requirements / Recommendations

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Product Update Form Description

Updated the 837 Healthcare Claim Professional Compile and Post logic to skip the Number of Services Allowed Per Claim APD rule for CPT codes that are defined as Add-On or Interactive Complexity.

Included Updates

2, 11, 12

Required Updates

None

Details
NEW2 CHANGED0 FIXED0
New (2)
MSO Approve/Pend/Deny Rule – 837 Health Care Claim Professional
The A/P/D rule has been updated to count the service as one service when a primary service has add-on add/or interactive complexity services.
Value Added: Enables agencies to submit the add-on and add/or interactive complexity services in the same claims as the primary service.
Topics
• 837 Health Care Claim Professional • Claims Processing • NX
 
MSO Approve/Pend/Deny Rule - Claim Processing Forms
The A/P/D rule has been updated to count the service as one service when a primary service has add-on or interactive complexity services.
Value Added: Enables agencies to submit the add-on and add/or interactive complexity services in the same claims as the primary service.
Topics
• Claims Processing • NX
 
Acceptance Tests
AV-88142 Summary | Details
MSO Approve/Pend/Deny Rule – 837 Health Care Claim Professional
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Professional
  • Admission (Outpatient)
  • Approve/Pend/Deny Rules Definition
  • Client Charge Input (Charge Fee Access)
  • Client Ledger
  • CPT Code Definition (MSO)
  • CPT Code Definition (PM)
  • Create Interim Billing Batch File
  • Crystal Report Viewer
  • Diagnosis
  • Electronic Billing
  • Financial Eligibility
  • Funding Source Registration
  • Guarantors/Payors
  • Import/Export File Configuration
  • Member Specific Information
  • MSO to Parent System Integration Mapping
  • Plan Definition
  • Program Maintenance
  • Provider Fee Definition
  • Registry Settings (PM)
  • Service Authorization
  • Service Fee/Cross Reference Maintenance
Scenario 1: 837 Health Care Claim Professional - Validating Approve/Pend/Deny - Number of Services Per Claim Allowed
Specific Setup:
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and interactive complexity codes associated in the definition.
  • Approve/Pend/Deny Rules Definition:
  • The desired fund sources contains a value of '1' in 'Number of Services Per Claim Allowed' and the desired value in 'Number of Services Per Claim Allowed Exceeded'.
  • Client 1:
  • Is associated to one of the funding sources in the ‘Approve/Pend/Deny Rules Definition’.
  • Service Authorization exists for the MSO CPT Service Codes for the primary code, add-on, and interactive complexity codes.
  • Services have been created for the client where some services are for the primary code only, and some services are for the primacy code with add-on and/or interactive complexity codes.
  • Close Charges has been used to close the charges.
  • Electronic Billing has been used to create claimed services.
  • The Inbound 837 Health Care Claim Professional file(s) have been loaded & compiled. Note the date this occurred.
Steps
  1. Open ‘837 Health Care Claim Professional’.
  2. Select ‘Run Report’ in ‘Options’.
  3. Set the ‘Start Date’ to the date the file was loaded & compiled.
  4. Select the desired file in ‘Select File’.
  5. Click [Process].
  6. Validate that the services in the report are appropriately approved, pended, or denied based on the ‘Approve/Pend/Deny Rules Definition’.
  7. Close the report.
  8. Select ‘Post File’ in ‘Options’.
  9. Set the ‘Start Date’ to the date the file was loaded & compiled.
  10. Select the desired file in ‘Select File’.
  11. Enter data for the required fields.
  12. Click [Process].
  13. Validate that the services in the report are appropriately approved, pended, or denied based on the ‘Approve/Pend/Deny Rules Definition’.
  14. Close the report.
  15. Repeat for additional files.
  16. Close the form.
Topics
• 837 Health Care Claim Professional • Claims Processing • NX
AV-89652 Summary | Details
MSO Approve/Pend/Deny Rule - Claim Processing Forms
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • Approve/Pend/Deny Rules Definition
  • Authorization Listing
  • Batch Creation
  • Batch Creation - Assign ID
  • Claim Processing (CMS 1500)
  • Claim Processing with Override (CMS 1500)
  • Client Ledger
  • Close Batch
  • CPT Code Definition (MSO)
  • CPT Code Definition (PM)
  • Diagnosis
  • Financial Eligibility
  • Funding Source Registration
  • Guarantors/Payors
  • Manual Batch Adjudication
  • Member Specific Information
  • MSO to Parent System Integration Mapping
  • Plan Definition
  • Program Maintenance
  • Provider Fee Definition
  • Registry Settings (PM)
  • Service Authorization
  • Service Fee/Cross Reference Maintenance
Scenario 1: Claim Processing (CSM 1500) Validating Approve/Pend/Deny - Number of Services Per Claim Allowed
Specific Setup:
  • MSO CPT Service Codes exist where the 'Primary' code has add-on and interactive complexity codes associated in the definition.
  • Approve/Pend/Deny Rules Definition:
  • The desired fund sources contains a value of '1' in 'Number of Services Per Claim Allowed' and a desired value in 'Number of Services Per Claim Allowed Exceeded'.
  • Client 1:
  • Is associated to one of the funding sources in the 'Approve/Pend/Deny Rules Definition'.
  • Service Authorization exists for the MSO CPT Service Codes for the primary code, add-on, and interactive complexity codes.
  • Batch Creation has been used to create a batch with a value of '1' in 'Total Entries’ and the desired amount‘ in 'Total Charges’. Note the batch number.
Steps
  1. Open ‘Claim Processing (CMS 1500)’.
  2. Select the batch created in setup.
  3. Select the ‘Member Name Or ID’.
  4. Select the ‘Provider’.
  5. Enter any desired data in the ‘Claim Processing (CMS 1500)’ section of the form.
  6. Select the ‘Service Detail’ section.
  7. Click [Add New Item].
  8. Enter data in all the required fields for the primary service.
  9. Validate that the ‘Claim Status’ is ‘Approved’.
  10. Click [Add New Item].
  11. Enter data in all the required fields for an add-on and/or interactive complexity.
  12. Validate that the ‘Claim Status’ is ‘Approved’.
  13. Add additional services as needed to meet the amount in 'Total Charges’.
  14. Validate that the ‘Claim Status’ is ‘Approved’.
  15. Click [Submit].
  16. Click [No].
  17. Open ‘Manual Batch Adjudication’.
  18. Select the batch created in setup.
  19. Click [Process].
  20. Click [OK].
  21. Close the form.
  22. Open ‘Close Batch’ and close the batch created in setup.
  23. Open ‘Client Ledger’.
  24. Select the ‘Simple’ report type and desired date range.
  25. Click [Process].
  26. Validate that the services exist.
  27. Close the report.
  28. Close the form.
Topics
• Claims Processing • NX

 

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