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Avatar MSO 2023 Monthly Release 2023.02.01
RADplus 2023 Monthly Release 2023.02.01

Product Update Description

The following issues are resolved: 1) Services are being approved over the annual dollar limit filed in the 'Plan Definition' form. 2) COB Adjustment Data goes missing after adding a subsequent TPL grid entry in the claim processing forms. 3) Automated 837 processing fails to process multiple threads.

Required Updates

None

Included Updates

None

Details
NEW0 CHANGED0 FIXED3
Fixed (3)
Plan Definition - Annual dollar limit
Resolves an issue to ensure that the services do not approve over the annual dollar limit filed for the plan. KB0073342 v0.01
Topics
• Claims Processing • NX
 
Claim Processing (CMS 1500) - Third Party Adjudication Data section
Resolves an issue to ensure that the subsequent third party adjudication data grid in the 'Claim Processing (CMS 1500)' form saves information correctly when there is an existing entry and more entries are added to the grid through 'Edit' option. KB0073338 v0.01
Topics
• Claims Processing • NX
 
Import/Export File Configuration - Process MSO 837P files
Resolves an issue to ensure that 837 Professional files in cloud are processing correctly.
Topics
• Claims Processing
 
Acceptance Tests
AV-87627 Summary | Details
Plan Definition - Annual dollar limit
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
  • Batch Creation
  • Batch Creation - Assign ID
  • Claim Processing (CMS 1500)
  • Contracting Provider Registration
  • CPT Code Definition (PM)
  • Dynamic Form - Admission - Client
  • Dynamic Form - Edit Service Fee Definition
  • Financial Eligibility
  • Funding Source Registration
  • MSO to Parent System Integration Mapping
  • Plan Definition
  • Provider Fee Definition
  • Service Authorization
  • Service Fee/Cross Reference Maintenance
Scenario 1: Claim Processing (CMS 1500) - Validating Annual Dollars Exhausted for the claim/service for the services over the annual dollar limit
Specific Setup:
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • CPT Code Definition:
  • An existing CPT code is identified, or a new CPT code is created. Note the CPT code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified. The 'Annual Maximum Dollars' is set to desired value.
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have at least one registration records with at least 1 license record. Note the performing provider number and name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated to include the performing provider added above. Note the contracting provider number and name.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, CPT codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record.
  • Service Authorization:
  • Create a new approved service authorization covering a CPT code created above.
  • Batch Creation:
  • Create a new batch. Note the batch number/name.
  • Approve/Pending/Deny Rule definition:
  • All Claim Processing Rules For Overall Plan Limitations are set to desired value.
Steps
  1. Open the 'Claim Processing (CMS 1500)' form.
  2. Select desired batch.
  3. Enter an ID in the ‘Member Name Or ID’ field.
  4. Enter a provider name in the ‘Provider’ field.
  5. Go to the ‘Service Detail’ section.
  6. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  7. Enter a date in the ‘Date Of Service’ field
  8. Enter a procedure code in the ‘Procedure Code’ field.
  9. Enter desired amount in the ‘Total Charge’ field.
  10. Enter desired number in the ‘Service Units’ field.
  11. Enter a number in the ‘Duration(Minutes)’ field.
  12. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  13. Click the ‘Display Valid Authorizations’ button.
  14. Verify the ‘Claim Status’ field is set to ‘Approved’.
  15. Submit the form.
  16. Open the 'Service Authorization' for the client.
  17. Add a new service for the different date. Note the authorization number.
  18. Open the 'Claim Processing (CMS 1500)' form.
  19. Select desired batch.
  20. Enter an ID in the ‘Member Name Or ID’ field.
  21. Enter a provider name in the ‘Provider’ field.
  22. Go to the ‘Service Detail’ section.
  23. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  24. Enter a date in the ‘Date Of Service’ field.
  25. Enter a procedure code in the ‘Procedure Code’ field.
  26. Enter amount in the ‘Total Charge’ field such that it exceeds the annual dollar limit defined in the plan definition.
  27. Enter desired number in the ‘Service Units’ field.
  28. Enter a number in the ‘Duration(Minutes)’ field.
  29. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  30. Select the system generated authorization number from the above step for the service.
  31. Click the ‘Display Valid Authorizations’ button.
  32. Verify the ‘Claim Status’ field is set to ‘Approved’.
  33. Open the 'Service Authorization' for the client.
  34. Verify the explanation of benefit displays the overall annual dollars exhausted message.
  35. Submit the form.
Topics
• Claims Processing • NX
AV-88165 Summary | Details
Claim Processing (CMS 1500) - Third Party Adjudication Data section
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • App Dashboard
  • Batch Creation
  • Batch Creation - Assign ID
  • Claim Processing (CMS 1500)
  • Claim Processing (UB-04)
  • Contracting Provider Registration
  • CPT Code Definition (PM)
  • Diagnosis
  • Dynamic Form - Admission - Client
  • Financial Eligibility
  • Plan Definition
  • Admission
  • Remittance Processing Widget
  • Revenue Code Definition (PM)
Scenario 1: Claim Processing (CMS 1500) - Validating COB Adjustment Data in the 'Third Party Adjudication' subsequent grid
Specific Setup:
  • Registry Settings:
  • The 'Add Support For The Input Of Third Party Payer Amounts' set to '2'.
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • CPT Code Definition:
  • An existing CPT code is identified, or a new CPT code is created. Note the CPT code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified. Note the plan id/name.
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have at least one registration records with at least 1 license record. Note the performing provider number and name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated to include the performing provider added above. Note the contracting provider number and name.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, CPT codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record.
  • Service Authorization:
  • Create a new service authorization covering a CPT code created above.
  • Batch Creation:
  • Create a new batch. Note the batch number/name. Note the batch name/number.
Steps
  1. Open the 'Claim Processing (CMS 1500)' form.
  2. Select desired batch.
  3. Enter an ID in the ‘Member Name Or ID’ field.
  4. Enter a provider name in the ‘Provider’ field.
  5. Go to the ‘Service Detail’ section.
  6. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  7. Enter a date in the ‘Date Of Service’ field
  8. Enter a procedure code in the ‘Procedure Code’ field.
  9. Enter an amount in the ‘Total Charge’ field.
  10. Enter a number in the ‘Service Units’ field.
  11. Enter a number in the ‘Duration(Minutes)’ field.
  12. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  13. Click the ‘Display Valid Authorizations’ button.
  14. Verify the ‘Claim Status’ field is set to ‘Approved’ or 'Denied' or 'Pended'.
  15. Click the ‘Enter Third Party Adjudication Data’ button.
  16. Verify the ‘Third Party Adjudication’ grid displays no data.
  17. Click the ‘New Row’ button.
  18. Enter a value in all the fields.
  19. Click on the ‘View’ button.
  20. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields with no data.
  21. Click the ‘New Row’ button to add the adjustment information for the service.
  22. Select a code in the ‘CAS adjustment Group Code’ field.
  23. Select a code in the ‘Adjustment Reason Code 1’ field.
  24. Enter an amount in the ‘Amount 1’ field.
  25. Enter a number in the ‘Quantity 1’ field.
  26. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  27. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  28. Click the ‘Submit’ button to save the claim information.
  29. Open the 'Claim Processing (CMS 1500)' form again.
  30. Select desired batch.
  31. Enter an ID in the ‘Member Name Or ID’ field.
  32. Enter a provider name in the ‘Provider’ field.
  33. Go to the ‘Service Detail’ section.
  34. Click the ‘Edit Item’ button to edit a row which is recently created.
  35. Click the ‘Enter Third Party Adjudication Data’ button.
  36. Verify the ‘Third Party Adjudication’ grid displays previously entered data correctly.
  37. Click on the ‘View’ button.
  38. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields with the data previously entered.
  39. Click the ‘New Row’ button to add new adjustment information for the service.
  40. Select a desired code in the ‘CAS adjustment Group Code’ field that is different from the code used in the above step.
  41. Select a desired code in the ‘Adjustment Reason Code 1’ field that is different from the code used in the above step.
  42. Enter an amount in the ‘Amount 1’ field.
  43. Enter a number in the ‘Quantity 1’ field.
  44. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  45. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  46. Click the ‘Submit’ button to save the claim information.
  47. Open the 'Claim Processing (CMS 1500)' form again.
  48. Select desired batch.
  49. Enter an ID in the ‘Member Name Or ID’ field.
  50. Enter a provider name in the ‘Provider’ field.
  51. Go to the ‘Service Detail’ section.
  52. Click the ‘Edit Item’ button to edit a row which is created in the above steps.
  53. Click the ‘Enter Third Party Adjudication Data’ button.
  54. Verify the ‘Third Party Adjudication’ grid correctly displays previously entered data.
  55. Click [View].
  56. Verify the grid displays two rows with the correct CAS adjustment Group Code, Adjustment Reason Code and Amount fields with the data entered in above steps.
Scenario 2: Claim Processing (UB 04) - Validating COB Adjustment Data in the 'Third Party Adjudication' subsequent grid
Specific Setup:
  • Registry Settings:
  • The 'Add Support For The Input Of Third Party Payer Amounts' set to '2'.
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • Revenue Code Definition:
  • An existing revenue code is identified, or a new revenue code is created. Note the revenue code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified. Note the plan id/name.
  • Performing Provider Registration:
  • Identify an existing performing provider registration or create a new performing provider registration to have at least one registration records with at least 1 license record. Note the performing provider number and name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated to include the performing provider added above. Note the contracting provider number and name.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, revenue codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record.
  • Service Authorization:
  • Create a new service authorization covering a revenue code created above.
  • Batch Creation:
  • Create a new batch. Note the batch number/name. Note the batch name/number.
Steps
  1. Open the 'Claim Processing (UB 04)' form.
  2. Select desired batch.
  3. Enter an ID in the ‘Member Name Or ID’ field.
  4. Enter a provider name in the ‘Provider’ field.
  5. Go to the ‘Service Detail’ section.
  6. Click the ‘Add New Item’ button to create a new row containing the service to be created.
  7. Enter a date in the ‘Date Of Service’ field
  8. Enter a procedure code in the ‘Procedure Code’ field.
  9. Enter an amount in the ‘Total Charge’ field.
  10. Enter a number in the ‘Service Units’ field.
  11. Enter a number in the ‘Duration(Minutes)’ field.
  12. Select ‘No’ in the ‘Does This Represent An Admission’ field.
  13. Click the ‘Display Valid Authorizations’ button.
  14. Verify the ‘Claim Status’ field is set to ‘Approved’ or 'Denied' or 'Pended'.
  15. Click the ‘Enter Third Party Adjudication Data’ button.
  16. Verify the ‘Third Party Adjudication’ grid displays no data.
  17. Click the ‘New Row’ button.
  18. Enter a value in all the fields.
  19. Click on the ‘View’ button.
  20. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields with no data.
  21. Click the ‘New Row’ button to add the adjustment information for the service.
  22. Select a code in the ‘CAS adjustment Group Code’ field.
  23. Select a code in the ‘Adjustment Reason Code 1’ field.
  24. Enter an amount in the ‘Amount 1’ field.
  25. Enter a number in the ‘Quantity 1’ field.
  26. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  27. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  28. Click the ‘Submit’ button to save the claim information.
  29. Open the 'Claim Processing (UB 04)' form again.
  30. Select desired batch.
  31. Enter an ID in the ‘Member Name Or ID’ field.
  32. Enter a provider name in the ‘Provider’ field.
  33. Go to the ‘Service Detail’ section.
  34. Click the ‘Edit Item’ button to edit a row which is created in the above steps.
  35. Click the ‘Enter Third Party Adjudication Data’ button.
  36. Verify the ‘Third Party Adjudication’ grid correctly displays previously entered data.
  37. Click on the ‘View’ button.
  38. Verify the grid displays the CAS adjustment Group Code, Adjustment Reason Code and Amount fields correctly display previously entered data.
  39. Click the ‘New Row’ button to add new adjustment information for the service.
  40. Select a desired code in the ‘CAS adjustment Group Code’ field that is different from the code used in the above step.
  41. Select a desired code in the ‘Adjustment Reason Code 1’ field that is different from the code used in the above step.
  42. Enter an amount in the ‘Amount 1’ field.
  43. Enter a number in the ‘Quantity 1’ field.
  44. Click the ‘Save’ button to save the adjustment information and return to the ‘Third Party Adjudication’ grid.
  45. Click the ‘Save’ button to save the Third Party information specified in the ‘Third Party Adjudication’ grid.
  46. Click the ‘Submit’ button to save the claim information.
  47. Open the 'Claim Processing (UB 04)' form again.
  48. Select desired batch.
  49. Enter an ID in the ‘Member Name Or ID’ field.
  50. Enter a provider name in the ‘Provider’ field.
  51. Go to the ‘Service Detail’ section.
  52. Click the ‘Edit Item’ button to edit a row which is created in the above steps.
  53. Click the ‘Enter Third Party Adjudication Data’ button.
  54. Verify the ‘Third Party Adjudication’ grid correctly displays previously entered data.
  55. Click [View].
  56. Verify the grid displays two rows with the correct CAS adjustment Group Code, Adjustment Reason Code and Amount fields correctly display previously entered data.
Topics
• Claims Processing • NX
AV-89125 Summary | Details
Import/Export File Configuration - Process MSO 837P files
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Import/Export File Configuration
Scenario 1: Import/Export Configurations form - Processing multiple automated inbound 837 professional / Institutional
Specific Setup:
  • New directories are created or an existing directory is identified to store the 837 files that needs to be processed, the files that are successfully processed and the error files.
  • Import/Export File Configuration:
  • Process File Path = An existing directory path for 837P files that needs to be processed.
  • Error File Path = An existing directory path to store error files.
  • Default 837 Professional Filing User = the logged in user.
  • Processing Interval = Desired value for how often the 837P directory (Process File Path field) will be checked for a file.
  • Interval Units = Desired unit in Hours, Minutes, or Seconds.
  • Auto-Process Actions = Desired value
  • Maximum Simultaneous File Processes = maximum number of simultaneous file compilation processes allowed for automatic 837 processing. Note the value.
  • Post Batch With Critical Errors = Desired option
  • Processed Folder File Path = Desired path for the new sub folder for processed files
Steps
  1. Place multiple 837 Professional and/or Institutional inbound files in the 'Process' directory.
  2. Check the 'Process' directory after time added to the 'Processing Interval' field.
  3. Validate that the files are processed successfully and moved to 'Error' or 'Success' directory.
Topics
• Claims Processing

 

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