Avatar MSO 837 Institutional Health Care Claim Processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Contracting Provider Registration
- 837 Health Care Claim Institutional
- 837 Health Care Claim Institutional - Compile Report
- 837 Health Care Claim Institutional - Post Report
Scenario 1: 'Contracting Provider Registration' - Form Verification
Specific Setup:
- One or more Avatar MSO Contracting Provider entries eligible for Contracting Provider Registration entry/edit
- Crystal Reports or other SQL reporting tool
Steps
- Open Avatar MSO 'Contracting Provider Registration' form.
- Enter/select Contracting Provider for Contracting Provider Registration entry/edit.
- Click 'Add' button to create new Contracting Provider Registration (or select existing Contracting Provider Registration record for edit).
- Enter/select values for all required/desired fields in main/first section of 'Contracting Provider Registration' form.
- Navigate to '837 Defaults' section of form.
- Ensure 'Require Exact Authorization Number (Institutional)' field is present in 'Contracting Provider Registration' form.
- Select Yes/No value for 'Require Exact Authorization Number (Institutional)' field (and any other '837 Defaults' section fields as desired).
- Click 'Submit' button to file 'Contracting Provider Registration' form.
- Open Avatar MSO 'Contracting Provider Registration' form.
- Enter/select previously filed Contracting Provider Registration record.
- Navigate to '837 Defaults' section of form.
- Ensure that previously selected Yes/No value is present in 'Require Exact Authorization Number (Institutional)' field.
- Open Crystal Reports or other SQL reporting tool.
- 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.
Scenario 2: '837 Health Care Claim Institutional' - Verification of 'Require Exact Authorization Number' Setting
Specific Setup:
- '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
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 - 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).
- 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).
- 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.
- Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
- Click 'Process' button.
- 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).
- 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).
- 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.
- Open Avatar MSO 'Claim Processing (UB-04)' form.
- Enter/select claims processing batch created via inbound 837 Institutional file posting.
- Select 837 Institutional claim for review.
- Navigate to 'Service Detail' section of form.
- Select service row for review and click 'Edit Selected Item' button.
- 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.
- 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).
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Topics
• 837 Health Care Claim Institutional
• Contracting Provider Registration
• NX
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Avatar MSO Claim Processing Batch Naming Convention
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Registry Settings (PM)
- Batch Creation
- Close Batch
- Fast Service Entry
- Fast Service Entry Submission
- 837 Health Care Claim Professional
- 837 Health Care Claim Institutional
Scenario 1: Avatar MSO Registry Settings - Verification of 'Set Batch File Naming Convention' Registry Setting
Steps
- Open 'Registry Settings' form.
- Enter search value 'Set Batch File Naming Convention' and click 'View Registry Settings' button.
- Ensure Registry Setting 'Set Batch File Naming Convention' is returned (under 'Avatar MSO-> Claims Processing' path).
- 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)."
Scenario 2: 'Fast Service Entry' - Verification of 'Set Batch File Naming Convention' Registry Setting
Specific Setup:
- 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
Steps
- Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
- Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
- Navigate to 'Fast Service Detail' section of form.
- Click 'Add New Item' button to enter new service.
- Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
- Enter/select values in all other service detail fields in form as required/desired.
- 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.
- Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
- 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:
- For default naming convention setting value '1' (Default), ensure that batch name includes 'Fast Service Entry Batch' followed by batch number
- Batch Name example: 'Fast Service Entry Batch 100'
- 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
- Registry Setting value examples: '1&2', '2&1'
- Batch Name examples (respectively): 'Fast Service Entry Batch Medicaid 100', 'Medicaid Fast Service Entry Batch 100'
- 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
- Registry Setting value examples: '1&2&3', '2&3'
- Batch Name examples (respectively): 'Fast Service Entry Batch Medicaid 2023-03-28 100', 'Medicaid 2023-03-28 100'
- 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
- Registry Setting value examples: '1&2&3&4', '2&4'
- Batch Name examples (respectively): 'Fast Service Entry Batch Medicaid Horizon House(1) 2023-03-28 100', 'Medicaid Horizon House(1) 100'
- 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
Scenario 3: '837 Health Care Claim Professional' - Verification of 'Set Batch File Naming Convention' Registry Setting
Specific Setup:
- 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
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 one or more claims are successfully compiled.
- Select 'Post File' in the 'Options' field, and select compiled 837 Professional file.
- Click 'Process' button to post 837 Professional file and create Avatar MSO claims processing batch(es).
- 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:
- For default naming convention setting value '1' (Default), ensure that batch name includes 'HIPAA837P Claim Processing Batch' followed by batch number
- Batch Name example: 'HIPAA837P Claim Processing Batch 100'
- 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
- Registry Setting value examples: '1&2', '2&1'
- Batch Name examples (respectively): 'HIPAA837P Claim Processing Batch Medicaid 100', 'Medicaid HIPAA837P Claim Processing Batch 100'
- 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
- Registry Setting value examples: '1&2&3', '2&3'
- Batch Name examples (respectively): 'HIPAA837P Claim Processing Batch Medicaid 2023-03-28 100', 'Medicaid 2023-03-28 100'
- 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
- Registry Setting value examples: '1&2&3&4', '2&4'
- 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
Scenario 4: '837 Health Care Claim Institutional' - Verification of 'Set Batch File Naming Convention' Registry Setting
Specific Setup:
- 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
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 one or more claims are successfully compiled.
- Select 'Post File' in the 'Options' field, and select compiled 837 Institutional file.
- Click 'Process' button to post 837 Institutional file and create Avatar MSO claims processing batch(es).
- 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:
- For default naming convention setting value '1' (Default), ensure that batch name includes 'HIPAA837I Claim Processing Batch' followed by batch number
- Batch Name example: 'HIPAA837I Claim Processing Batch 100'
- 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
- Registry Setting value examples: '1&2', '2&1'
- Batch Name examples (respectively): 'HIPAA837I Claim Processing Batch Medicaid 100', 'Medicaid HIPAA837I Claim Processing Batch 100'
- 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
- Registry Setting value examples: '1&2&3', '2&3'
- Batch Name examples (respectively): 'HIPAA837I Claim Processing Batch Medicaid 2023-03-28 100', 'Medicaid 2023-03-28 100'
- 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
- Registry Setting value examples: '1&2&3&4', '2&4'
- 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
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Topics
• 837 Health Care Claim Institutional
• 837 Health Care Claim Professional
• Claims Processing
• NX
• Registry Settings
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Avatar MSO 'Provider EOB Report'
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Provider EOB Report
- Provider EOB Report - Report Display
Scenario 1: 'Provider EOB Report' - Form and Report Verification
Specific Setup:
- One or more EOB(s) existing in system for display
Steps
- Open Avatar MSO 'Provider EOB Report' form (under 'Avatar MSO / MSO Reporting / Provider Management Reports' menu).
- Ensure 'Contracting Provider' EOB criteria field is required; enter/select Contracting Provider value.
- 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
- Ensure 'EOB' dropdown selection field populated with existing EOBs for selected Contracting Provider (including EOB Number, Date, Provider and Amount values in display).
- Select EOB for Provider EOB Report display.
- Click 'Launch EOB Report' button to view Provider EOB Report.
- In Provider EOB Report display, ensure that EOB/Service Remittance Advice information is displayed, including the following information where applicable:
- EOB Number
- EOB Amount
- EOB Date
- Check Number
- Check Amount
- Check Date
- Provider (including Provider Address information)
- Client Name / Client ID / Client DOB / Client Gender
- Date Claim Received
- 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)
- 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:
- Current Claims
- Adjustment Total
- Client Name
- 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)
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Topics
• NX
• Reports
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Avatar MSO Service Authorization Widgets
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Pending Service Authorizations Widget
- Service Authorization Information Widget
Scenario 1: 'Pending Service Authorization' Widget - Widget Display Verification
Specific Setup:
- One or more 'Pending' status Service Authorization record(s)
- 'Pending Service Authorizations' widget must be assigned to user/home view
Steps
- 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.
- 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.
- 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
Scenario 2: 'Service Authorization Information' Widget - Widget Display Verification
Specific Setup:
- One or more clients with existing Member Service Authorization records
- Avatar MSO 'Service Authorization Information' widget must be assigned to user/home view
Steps
- 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).
- 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.
- 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.
- 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
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Topics
• NX
• Service Authorizations
• Widgets
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Avatar MSO 'Service Authorization Request' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Authorization Grouping Definition
- Service Authorization Request
Scenario 1: 'Service Authorization Request' - Form Verification
Specific Setup:
- 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)
Steps
- Open Avatar MSO 'Service Authorization Request' form.
- Enter/select client for Service Authorization Request entry.
- 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.
- Select 'Grouping' in 'Authorization Grouping Or Individual Authorizations' field.
- Select defined CPT/Revenue Code Group in 'Authorization Grouping' field.
- Ensure 'Procedure Code Type' and 'Code Authorized' fields are populated with CPT Codes and Revenue Codes as defined for selected Authorization Grouping.
- Ensure 'Requested Units' and 'Units Authorized' fields are populated with CPT Codes and Revenue Codes as defined for selected Authorization Grouping.
- Edit/select values for any other 'Service Authorization Request' form fields as required/desired.
- Click 'Submit' button to file 'Service Authorization Request' form/record.
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Topics
• NX
• Service Authorizations
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Avatar MSO 837 Health Care Claim Forms
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 Institutional
Scenario 1: '837 Health Care Claim Professional' - Verification of 'Select File' field selection limit
Specific Setup:
- One or more loaded, compiled and/or posted inbound 837 Professional format files
- Crystal Reports or other SQL reporting tool
Steps
- Open Avatar MSO '837 Health Care Claim Professional' form.
- Select 'Load File' in the 'Options' field.
- Enter file path for inbound 837 Professional format file and click 'Process' button.
- Select 'Compile File', 'Run Report', 'Run Error Report', 'Post File', 'Dump File' or 'Delete Loaded/Compiled File' in the 'Options' field.
- Enter/select value in 'Contracting Provider' field.
- 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
- Click the 'Select File' field to expand/display files available for selection.
- 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.
- 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
- 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
- Enter values for 'Start Date' and/or 'End Date' file selection filter fields in form.
- Click the 'Select File' field to expand/display files available for selection.
- 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.
- 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
- 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.
- Open Crystal Reports or other SQL reporting tool.
- 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.
Scenario 2: '837 Health Care Claim Institutional' - Verification of 'Select File' field selection limit
Specific Setup:
- One or more loaded, compiled and/or posted inbound 837 Institutional format files
- Crystal Reports or other SQL reporting tool
Steps
- Open Avatar MSO '837 Health Care Claim Institutional' form.
- Select 'Load File' in the 'Options' field.
- Enter file path for inbound 837 Institutional format file and click 'Process' button.
- Select 'Compile File', 'Run Report', 'Run Error Report', 'Post File', 'Dump File' or 'Delete Loaded/Compiled File' in the 'Options' field.
- Enter/select value in 'Contracting Provider' field.
- 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
- Click the 'Select File' field to expand/display files available for selection.
- 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.
- 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
- 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
- Enter values for 'Start Date' and/or 'End Date' file selection filter fields in form.
- Click the 'Select File' field to expand/display files available for selection.
- 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.
- 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
- 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.
- Open Crystal Reports or other SQL reporting tool.
- 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.
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Topics
• 837 Institutional
• 837 Professional
• NX
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Avatar MSO Claim Processing Forms
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Fast Service Entry
- Claim Processing (CMS 1500)
- Claim Processing (UB-04)
Scenario 1: 'Fast Service Entry' - Form Verification
Specific Setup:
- Client record eligible for claim/service entry
Steps
- Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
- Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
- Navigate to 'Fast Service Detail' section of form.
- Click 'Add New Item' button to enter new service.
- Enter/select client for service entry in 'Member Name or ID' field.
- Ensure that 'Does This Service Represent An Admission' field is not required in form.
- Enter/select values in all other service detail fields as required/desired.
- 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.
- Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
- 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.
Scenario 2: 'Claim Processing (CMS 1500)' - Form Verification
Specific Setup:
- Client record with one or more CMS 1500 (Professional) claim(s)/service(s) for adjudication (or eligible for claim/service entry)
Steps
- Open Avatar MSO 'Claim Processing (CMS 1500)' form (and/or 'Claim Processing With Override (CMS 1500)' form).
- Select claims processing batch for service entry/edit.
- Open existing claim for adjudication or create new claim for service entry/edit.
- Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
- Navigate to 'Service Detail' section of form.
- Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
- Ensure that 'Does This Service Represent An Admission' field is not required in form.
- Enter/select values in all other service detail fields as required/desired.
- 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)).
- Click 'Submit' button to file 'Claim Processing (CMS 1500)' form (or 'Claim Processing With Override (CMS 1500)' form) and claim/service(s).
Scenario 3: 'Claim Processing (UB-04)' - Form Verification
Specific Setup:
- Client record with one or more UB-04 (Institutional) claim(s)/service(s) for adjudication (or eligible for claim/service entry)
Steps
- Open Avatar MSO 'Claim Processing (UB-04)' form (and/or 'Claim Processing With Override (UB-04)' form).
- Select claims processing batch for service entry/edit.
- Open existing claim for adjudication or create new claim for service entry/edit.
- Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
- Navigate to 'Service Detail' section of form.
- Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
- Ensure that 'Does This Service Represent An Admission' field is not required in form.
- Enter/select values in all other service detail fields as required/desired.
- 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)).
- Click 'Submit' button to file 'Claim Processing (UB-04)' form (or 'Claim Processing With Override (UB-04)' form) and claim/service(s).
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Topics
• Claims Processing
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Avatar ProviderConnect NX Additional Support
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Authorization Hardcopy
- Authorization Hardcopy - Report Display
- Fast Service Entry Submission
- Retro Claim Adjudication
- Void Claim Assignment
Scenario 1: 'Authorization Hardcopy' - Form and Report Verification
Specific Setup:
- One or more Service Authorization record(s) for report selection/display
Steps
- Open Avatar MSO 'Authorization Hardcopy' form (under 'Avatar MSO / MSO Reporting / Care Management Reports' menu).
- Enter/select value in 'Provider' field.
- 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
- Select value for 'All or Individual Members' (and select Member if 'Individual' selected).
- Select Service Authorization for Authorization Hardcopy report display in 'Member Authorization' field.
- Click 'Process Report' button to view Authorization Hardcopy report.
- In Authorization Hardcopy report display, ensure that Service Authorization information is displayed, including the following information where applicable:
- Authorization Number
- Authorization Date Range
- Provider
- Member
- Authorization Grouping:
- Authorized Group Or Individual
- Current Authorization Status
- Current Auth. Status Reason
- Initial Or Continued Authorization
- Next Review Date
- Performing Provider
- Performing Provider Type
- Auth Level Care
- Type Of Authorization
- Letter Type
- Level Of Care
- Primary Diagnosis
- Secondary Diagnosis
- Procedure Codes (including Code, Units Authorized, Estimated Liability Code and Totals)
- Internal Comments
- Comments On Authorization
- Financial Eligibility
Scenario 2: 'Fast Service Entry Submission' - Form Verification
Specific Setup:
- Client record eligible for claim/service entry
Steps
- Open Avatar MSO 'Fast Service Entry Submission' form (under 'Avatar MSO / Claims Processing' menu).
- 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).
- 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).
- 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.
- Navigate to 'Fast Service Detail' section of form.
- Click 'Add New Item' button to enter new service.
- Enter/select client for service entry in 'Member Name or ID' field.
- Ensure that 'Funding Source' field contains only selections applicable to Contracting Provider Registration; enter/select value in 'Funding Source' field.
- Enter/select value in 'Provider' field.
- Ensure that 'Performing Provider' field contains only selections applicable to Contracting Provider Registration; select value in 'Performing Provider' field if desired.
- Enter value in 'Begin Date Of Authorization' and 'End Date Of Authorization' field.
- Select value in 'Date Of Service' field.
- Enter/select value in 'Procedure Code' field.
- Enter value in 'Total Charge' and 'Service Units' field.
- Enter value in 'Authorization Number' field, or click 'Display Valid Authorizations' button and select Service Authorization applicable to service entry.
- Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO claim/service adjudication rules and requirements.
- 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.
- 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'.
- Enter/select values in any other fields as required/desired.
- 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.
- 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).
- 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).
- 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).
- 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.
Scenario 3: 'Void Claim Assignment' - Form Verification
Specific Setup:
- 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)
Steps
- Open Avatar MSO 'Void Claim Assignment' form (under 'Avatar MSO / Claims Processing' menu).
- Ensure that the following fields are present in 'Void Claim Assignment' form:
- 'From Date Of Service'
- Begin date of service to include for Void service selection; Required
- 'Through Date Of Service'
- Begin date of service to include for Void service selection; Required
- 'Client ID'
- Client ID for Void service selection; Required
- 'Contracting Provider'
- Contracting Provider for Void service selection filtering; Optional
- 'Contracting Provider Program'
- Contracting Provider Program for Void service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
- 'Select Services To Void' button
- 'File' button
- Enter value for 'From Date Of Service' and 'Through Date of Service' criteria fields.
- 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.
- Enter/select value for 'Client ID' criteria field.
- Enter/select value for 'Contracting Provider' criteria field if desired.
- 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
- Select value for 'Contracting Provider Program' criteria field if desired.
- Click 'Select Services To Void' button to display Void service selection dialog for service selection criteria entered.
- 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.
- 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.
- 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:
- 'Batch'
- 'Contracting Provider'
- 'Date Of Service'
- 'Claim #'
- 'Procedure Code'
- 'Charges'
- 'Total Disbursement'
- Select one or more service(s) for 'Void' Retro Claim Adjudication entry (using checkbox selection field for each desired service).
- Click 'OK' button in the 'Select Service(s) To Void' to complete Void service selection.
- Click 'File' button in 'Void Claim Assignment' form to file 'Void' (full takeback) Retro Claim Adjudication entry for each/all selected service(s).
- 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.
- On Void Claim Assignment filing, ensure user is presented with a confirmation dialog noting 'Filed'; click 'OK' button to close confirmation dialog.
- 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.
- 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.
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Topics
• Claims Processing
• NX
• Reports
• Retro Claim Adjudication
• Service Authorizations
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