Avatar MSO 2023 Update 27

Last updated
Save as PDF

Product Requirements and Recommendations

Avatar MSO required
RADplus required

Recommended Update Level

Avatar MSO 2023 Monthly Release 2023.02.00
RADplus 2023 Monthly Release 2023.02.00

Product Update Description

The following issues are resolved: 1) 'Fast Service Entry' claim status over-rides are not being recognized when services are re-adjudicated. 2) 'Claims Adjudication Rules Definition' are not correctly adjudicated for procedure code groupings that contain CPT/Revenue codes with colon(s).

Required Updates

Avatar MSO 2023 Update 2

Included Updates

2, 11, 12, 13

Details

NEW0 CHANGED0 FIXED2

Fixed (2)

AV-90066 Details \| User Acceptance Tests Fast Service Entry An issue is resolved to ensure that claim status over-rides are being applied when services are re-adjudicated. KB0074497 v0.01	Topics • Claims Processing • NX

AV-90240 Details \| User Acceptance Tests Claims Adjudication Rules Definition An issue has been resolved to ensure that definitions for procedure code groupings that contain CPT/Revenue codes with colon(s) are correctly adjudicated. KB0074498 v0.01	Topics • Claims Processing • NX

Acceptance Tests

AV-90066 Summary | Details

Fast Service Entry

Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:

Admission (Outpatient)
Authorization Listing
Claim Processing (CMS 1500)
Claim Service Detail Override Warning
Diagnosis
Fast Service Entry
Fast Service Entry Filing Confirmation
Financial Eligibility
Member Specific Information
MSO to Parent System Integration Mapping
Provider Fee Definition
Registry Settings (MSO)
Service Authorization

Scenario 1: Fast Service Entry - Claim Status Over-Ride - Re-Adjudicated

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 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.
Verify the Claim Status is set to the correct value for the authorization record.
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). Note the batch number.
Open 'Manual Batch Adjudication' to select and process the batch,
Open desired 'Claim Processing for to review the batch.
Ensure that the 'Claim Status' is correct.
Close the form.

Topics

• Claims Processing • NX

AV-90240 Summary | Details

Claims Adjudication Rules Definition

Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:

Admission
Authorization Listing
Batch Creation
Batch Creation - Assign ID
Claim Processing (CMS 1500)
Claim Processing (UB-04)
Claims Adjudication Rules Definition
CPT Code Definition (MSO)
CPT Code Definition (PM)
Diagnosis
Financial Eligibility
Funding Source Registration
Manual Batch Adjudication
Member Specific Information
MSO to Parent System Integration Mapping
Plan Definition
Procedure Code Group Definition
Program Maintenance
Provider Fee Definition
Revenue Code Definition (MSO)
Revenue Code Definition (PM)
Service Authorization
Service Fee/Cross Reference Maintenance

Scenario 1: Claims Adjudication Rules Definition - Procedure Code Grouping that contains CPT/Revenue codes with colons.

Specific Setup:

CPT Code Definition and/or Revenue Code Definition exists where a colon is in the code (Ex: '90834:93' or '910:25').
Claims Adjudication Rules Definition:
Desired rules exist for desired rule types: 'Comparison', 'Existence', and/or 'Limit' that contain the CPT Code Definition above, or the Revenue Code Definition above.
Note the rules and conditions of the rules.

Client record eligible for claim/service entry.

Steps

Use ‘Batch Creation’ to create a batch’.
Using the desired ‘Claim Processing’ form create services, for the batch, that tests the conditions of the rules noted in setup.
Verify that the status is correct for the service(s) based on the rule definitions.
Submit the form.
Use ‘Manual Batch Adjudication’ to manually adjudicate the batch.
Using the desired ‘Claim Processing’ form review the service and the status, ensuring that the status is correct for the rule definition.

Topics

• Claims Processing • NX

Table Changes

Table	Column	Change
SYSTEM.claim_adjud_rules_def	CheckExistence	Method update
SYSTEM.claim_adjud_rules_def	CheckLimit	Method update