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Avatar MSO 2023 Update 33

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Product Requirements and Recommendations

Avatar MSO required
RADplus required

Recommended Update Level

Avatar MSO 2023 Monthly Release 2023.02.02
RADplus 2023 Monthly Release 2023.02.02

Product Update Description

The issue is resolved where 'Limit' rules defined via the 'Claim Adjudication Rules Definition' form fails to recognize when the limit is exceeded.

Required Updates

Avatar MSO 2023 Update 27

Included Updates

2, 3, 11, 12, 13, 20, 27, 29

Details
NEW0 CHANGED0 FIXED1
Fixed (1)
Avatar MSO 'Claims Adjudication Rule Definition'
An issue is resolved to ensure that 'Limit' rules defined via the 'Claims Adjudication Rules Definition' form correctly identify when defined rule limits are exceeded for Avatar MSO Claim Processing/Service Adjudication. KB0074974 v0.01
Topics
• Claims Adjudication Rule Definition • Claims Processing • NX
 
Acceptance Tests
AV-90482 Summary | Details
Avatar MSO 'Claims Adjudication Rule Definition'
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Institutional
  • 837 Health Care Claim Professional
  • Claim Processing (CMS 1500)
  • Claim Processing (UB-04)
  • Claims Adjudication Rules Definition
  • Close Batch
  • Fast Service Entry
  • Manual Batch Adjudication
Scenario 1: Avatar MSO Claim Processing - Verification of 'Claims Adjudication Rule Definition' Limit Function
Specific Setup:
  • One or more Claims Adjudication Rules with 'Limit' entry defined/filed in system applicable to claims/services for adjudication
  • Client with eligible Service Authorization record(s) valid for service entry/claim processing
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO 'Claims Adjudication Rules Definition' form.
  2. Select 'Add' in 'Action' field (or select 'Edit' and select existing rule for review/edit).
  3. Enter/select values for 'Rule ID', 'Rule Description', 'Status', 'Status Reason' and 'Funding Source fields (and 'From Date'/'Through Date' fields if desired).
  4. Select 'Limit' in 'Rule Type' field.
  5. Select/define 'Limit' rule criteria/values using 'The Sum/Total Of', 'Within The Past', 'For The Following Procedure Code' ('Or Procedure Code Group'), 'Must Be', 'The Following Value' and 'For Diagnosis' fields.
  6. Select values for 'For Same Provider' and 'Pay Partial Claim' fields.
  7. Click 'Add Rule' button to save entry for Claims Adjudication Rule 'Limit' entry.
  8. Repeat 'Limit' rule entry/addition as desired.
  9. Click 'Submit' button to file 'Claims Adjudication Rules Definition' form and 'Limit' rule.
  10. Enter one or more claims/services in Avatar MSO using Funding Source and CPT/Revenue Code values where Claims Adjudication Rule 'Limit' entry is defined/applicable for claim processing/adjudication.
  11. Note - Claim/Service entry may be done via 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms, '837 Health Care Claim Professional'/'837 Health Care Claim Institutional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
  12. Adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, nightly automatic adjudication process and/or 'Close Batch' function).
  13. Note - Claims Adjudication Rule functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) with Claim Adjudication Rule(s) applicable claims/services must be adjudicated to reflect rules; Claims Adjudication Rules will not be immediately reflected in Claim Processing forms during initial service entry or in 837 file compilation/posting reports
  14. Following batch/claim/service adjudication - open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
  15. Navigate to 'Service Detail' section of form.
  16. Select service row and click 'Edit Selected Item'.
  17. Ensure that in case where service has been adjudicated/status set by Claims Processing Adjudication Rule, upon opening service user is presented with 'Claim Processing...' form alert dialog noting 'This service has been overwritten by 'Claims Adjudication Rules Definition'. Any changes to this service will remove that change until the process is run again.'
  18. Ensure that Claims Adjudication Rules Definition entries are evaluated against claim/service information; in case where service information matches Claim Adjudication 'Limit' rule entry information/criteria and exceeds defined limit for rule (in combination with all other 'Approved' status services existing for client within single/multiple claims and under single/multiple batches), ensure that service is set to 'Denied' or 'Pending' state (per 'Claims Adjudication Rules Definition' form entry).
  19. 'Explanation of Coverage' field will include detail of Claims Adjudication Rule entry failed/exceeded for adjudication
  20. Example: 'The service was denied for the following reason: Claim Status has been set to D because of Claim Adjudication Rule L_99097 - Limit Rule Code 99097'
Topics
• Claims Adjudication Rule Definition • Claims Processing • NX
Table Changes
Table Column Change
SYSTEM.claimadjudrulesdef CheckLimit CodeFix