Automated Processing - 837 Professional
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- Import/Export File Configuration
- 837 Health Care Claim Professional Automated Processing
- Admission (Outpatient)
- Approve/Pend/Deny Rules Definition
- Claim Processing Automation
- Contracting Provider Registration
- CPT Code Definition (MSO)
- CPT Code Definition (PM)
- Create Interim Billing Batch File
- Diagnosis
- Electronic Billing
- Financial Eligibility
- Guarantors/Payors
- Member Specific Information
- MSO to Parent System Integration Mapping
- Plan Definition
- Program Maintenance
- Provider Fee Definition
- Service Authorization
- Service Fee/Cross Reference Maintenance
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
- Place multiple 837 Professional and/or Institutional inbound files in the 'Process' directory.
- Check the 'Process' directory after time added to the 'Processing Interval' field.
- Validate that the files are processed successfully and moved to 'Error' or 'Success' directory.
Scenario 2: Professional Automated 837 Inbound Processing/Claim Processing Automation - Data Validation
Specific Setup:
- Avatar MSO Automated 837 Health Care Claim Processing must be enabled and configured for system (via Avatar MSO 'Import/Export File Configuration' form)
- Avatar MSO Automated 837 Health Care Claim Processing may optionally be configured to automatically close batch(es) after 837 posting, create Vouchers and/or create EOBs (via Avatar MSO 'Claim Processing Automation' form)
- Inbound 837 Professional files for automated processing containing multiple valid claims/services
Steps
- Place multiple 837 Professional inbound files in 'Processing' directories for Avatar MSO Automated inbound 837 Health Care Claim processing (as defined via 'Import/Export File Configuration' form).
- Ensure Avatar MSO Automated inbound process for 837 Professional files loads/compiles/posts each 837 inbound file in 'Processing' directories (according to behavior defined via 'Import/Export File Configuration' form).
- Ensure for all Claims Processing batches created via inbound 837 automated processing are closed automatically if configured (as defined in the 'Claim Processing Automation' form). This can be confirmed via 'Close Batch' form, the 'Open Batches' Widget and/or by reviewing data in Avatar MSO SQL table 'SYSTEM.batch_current_data.'
- Ensure that inbound 837 automated processing completes for all 837 inbound files placed in 'Processing' directories, and that files are correctly moved to 'Processed' directories.
- Ensure that all posted inbound 837 claims/services are adjudicated (Approved/Denied) following 837 Professional file posting (according to Avatar MSO adjudication criteria in Approve/Pend/Deny Rules Definition, service requirements, service authorization limits, etc).
- Ensure that no system errors are recorded in the 'Error' file directory .txt file (as defined in the 'Import/Export File Configuration' form) for processed 837 inbound files.
- If 999 Functional Acknowledgement response files are configured for generation on 837 file automated processing - ensure that on inbound 837 file processing, 999 Functional Acknowledgement response file(s) are automatically generated on server in directory specified for 999 file creation in the 'Import/Export File Configuration' form.
- If 277CA Claim Acknowledgement response files are configured for generation on 837 file automated processing - ensure that on inbound 837 file processing, 277CA Claim Acknowledgement response file(s) are automatically generated on server in directory specified for 277CA file creation in the 'Import/Export File Configuration' form.
- Ensure that Avatar MSO Claim Processing batch(es) are closed following 837 file automated processing (and Vouchers/EOBs created if applicable) as defined in the 'Claim Processing Automation' form.
- If 835 Health Care Claim Payment/Advice response files are configured for generation on EOB creation - ensure that on EOB creation (manually via 'Create EOB' form or via automated claims processing functionality including scheduled EOB creation), 835 Health Care Claim Acknowledgement response file(s) are automatically generated on server in directory specified for 835 file creation in the 'Claim Processing Automation' form.
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Topics
• Claims Processing
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