Avatar MSO 837 Professional/837 Institutional Health Care Claim Processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- 837 Health Care Claim Professional
- 837 Health Care Claim Professional - Compile Report
- 837 Health Care Claim Professional - Error Report
- Benefit Enrollment and Maintenance (834)
- Contracting Provider Registration
- Funding Source/Guarantor Mapping
- Guarantors/Payors
- Registry Settings (PM)
- 837 Health Care Claim Institutional
- 837 Health Care Claim Institutional - Compile Report
- 837 Health Care Claim Institutional - Error Report
Scenario 1: '837 Health Care Claim Professional' - Verification of Funding Source Determination
Specific Setup:
- 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
Steps
- Open Avatar MSO '837 Health Care Claim Professional' form.
- Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
- Select 'Load File' in the 'Options' field.
- Enter file path for inbound 837 Professional format file and click 'Process' button.
- Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
- Click 'Process' button.
- 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.
- 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')
- 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
- 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
- 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
- Select 'Post File' in the 'Options' field.
- Select compiled 837 Professional format file and click 'Process' button.
- 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).
- 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.
- Select compiled/Posted 837 Professional format file and click 'Process' button.
- 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.
- 837 Error Message Example: 'Funding Source not found based on policy number: 123456A and service date: 03/01/2023 for member: 123'
- Open 'Batch Creation' form.
- Select batch created via 837 Professional inbound file posting.
- Ensure that 'Funding Source' value for batch is present/same as determined by 837 Professional file compilation/posting.
Scenario 2: '837 Health Care Claim Institutional' - Verification of Funding Source Determination
Specific Setup:
- 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
Steps
- Open Avatar MSO '837 Health Care Claim Institutional' form.
- Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
- Select 'Load File' in the 'Options' field.
- Enter file path for inbound 837 Institutional format file and click 'Process' button.
- Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
- Click 'Process' button.
- 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.
- 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')
- 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
- 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
- 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
- Select 'Post File' in the 'Options' field.
- Select compiled 837 Institutional format file and click 'Process' button.
- 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).
- 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.
- Select compiled/Posted 837 Institutional format file and click 'Process' button.
- 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.
- 837 Error Message Example: 'Funding Source not found based on policy number: 123456A and service date: 03/01/2023 for member: 123'
- Open 'Batch Creation' form.
- Select batch created via 837 Institutional inbound file posting.
- Ensure that 'Funding Source' value for batch is present/same as determined by 837 Institutional file compilation/posting.
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Topics
• 837 Health Care Claim Institutional
• 837 Health Care Claim Professional
• NX
• Registry Settings
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