Avatar MSO 2023 Update 34

1. Open 'Registry Settings' form.
2. Enter search value 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' is returned (under 'Avatar MSO -> Claim Processing' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"If 'Y' is selected the 'Set up Co-Pay based on Avatar PM 834' form will be added. PM 834 data will be used to determine the appropriate row in this form to be used to determine the co-pay.

Selecting 'N' removes the form and disables the related functionality."

• Avatar MSO Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form (under 'Avatar MSO / System Maintenance' menu).
2. Note - 'Set Up Co-Pay Based On Avatar PM 834' form is only available where Avatar MSO Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' is enabled
3. Ensure the following fields/items are present in 'Set Up Co-Pay Based On Avatar PM 834' form:
4. 'New Row' / 'Delete Row' buttons
5. 'Rule Name'
6. Name value for Co-Pay/834 Eligibility Assignment entry (required)
7. 'Effective Date'
8. Dictates earliest Date of Service value to apply Co-Pay/834 Eligibility Assignment entry (required)
9. 'Expiration Date'
10. Dictates latest Date of Service value to apply Co-Pay/834 Eligibility Assignment entry (optional)
11. '834 Segment Containing Co-Pay Indicator'
12. Dictates 834 Eligibility Data segment to be compared to 'Co-Pay Indicator Value' to apply Co-Pay/834 Eligibility Assignment entry (required)
13. If '2300-HD-04' is selected, 'Co-Pay Indicator Value' will be compared to Health Coverage (2300-HD) segment values in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' field 'eligibility_category'
14. If '2300-REF-02' is selected, 'Co-Pay Indicator Value' will be compared to Health Coverage Policy Number (2300-REF) segment values in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' field 'reference_identification' (filed where 2300-REF-01 Qualifier = '17 - Client Reporting Category')
15. 'Co-Pay Indicator Value'
16. Dictates 'Co-Pay Indicator Value' for selected 834 Eligibility Data segment to apply Co-Pay/834 Eligibility Assignment entry (required)
17. 'Co-Pay Indicator Location within the Segment'
18. Dictates portion of selected Co-Pay Indicator 834 segment/value to use for 'Co-Pay Indicator Value' comparison (optional)
19. 'Apply as Co-Pay or Private Pay'
20. Dictates whether 'How Much Co-Pay to Apply' value from Co-Pay/834 Eligibility Assignment entry should be filed in 'Member Co-Pay' or 'Private Pay Amount' fields (required)
21. Note - Co-Pay or Private Pay should be selected based on which field present in Avatar MSO Claims Processing forms/according to 'Enable Private Pay Amount' Registry Setting
22. 'Funding Source(s) Co-Pay Applies To' (and 'Current Order' field for entries)
23. Dictates Funding Source(s) to apply Co-Pay/834 Eligibility Assignment entry for (required)
24. Note - Enter search term/click 'Process Search' and select entry to add; multiple Funding Sources may be selected by repeating/adding to 'Current Order' list
25. 'Revenue Code(s) that Trigger Co-Pay' (and 'Current Order' field for entries)
26. Dictates Revenue Code(s) to apply Co-Pay/834 Eligibility Assignment entry for (optional)
27. Note - If no Revenue Codes specified/selected, Co-Pay/834 Eligibility Assignment entry will apply to all Revenue Codes for UB-04/Institutional services
28. Note - Enter search term/click 'Process Search' and select entry to add; multiple Revenue Codes may be selected by repeating/adding to 'Current Order' list
29. 'How Much Co-Pay to Apply'
30. Dictates amount/value to file as Co-Pay/Private Pay Amount for first service in claim where Co-Pay/834 Eligibility Assignment entry applied (required)
31. 'File' button
32. Click 'New Row' button to add Co-Pay/834 Eligibility Assignment entry (or select existing row in grid for view/edit).
33. Enter/select values in all 'Set Up Co-Pay Based On Avatar PM 834' form fields as required/desired.
34. Repeat entry for one or more Co-Pay/834 Eligibility Assignment rows if desired.
35. Click 'File' button to save/file all Co-Pay/834 Eligibility Assignment entries added/updated in form; ensure user is presented with dialog noting 'Filed successfully.'
36. Click 'OK' button to return to 'Set Up Co-Pay Based On Avatar PM 834' form (or optionally close/re-open form).
37. Ensure all previously entered/filed Co-Pay/834 Eligibility Assignment entries are present in form; select one or more rows and confirm field values present as previously entered/filed.
38. Open Crystal Reports or other SQL reporting tool.
39. In Avatar MSO SQL table 'SYSTEM.co_pay_per_pm_834', ensure row(s) are present for all Co-Pay/834 Eligibility Assignment entries filed via 'Set Up Co-Pay Based On Avatar PM 834' form, including field values as entered/selected/filed in form.

• Avatar MSO Registry Setting 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' must be enabled
• Note - Avatar PM 2023 Update 58 is required for support of the 'Determine Inpatient Co-Pay Based on Avatar PM 834 Data' Registry Setting/functionality
• Avatar MSO Registry Setting 'Enable Private Pay Amount' may optionally be enabled (for use of 'Private Pay Amount' field in lieu of 'Member Co-Pay'/'Member Deductible' fields)
• One or more Claim Status Reason Codes (associated to Claim Adjustment Reason Code) may optionally be defined (for use of 'Other Adjustment' Co-Pay From 834 setup)
• 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)
• 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)
• Claims/services for Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' for PATID/Subscriber Unique ID)
• One or more 'Co-Pay From Avatar PM 834 Setup' entries applicable to Client/Provider/Service Dates/Funding Source/Revenue Codes and 834 Co-Pay Indicator (via Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form)

1. Enter one or more Institutional/UB-04 claims/services in Avatar MSO using Client, Provider, Funding Source and Revenue Code values where 'Co-Pay From Avatar PM 834 Setup' entry is defined/applicable for claim processing/adjudication.
2. Note - Institutional Claim/Service entry using Revenue Codes may be done via 'Claim Processing (UB-04)' forms and '837 Health Care Claim Institutional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
3. Adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, nightly automatic adjudication process and/or 'Close Batch' function).
4. Note - The 'Co-Pay From Avatar PM 834 Setup' claim processing/service co-pay or private pay assignment functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing 'Co-Pay From Avatar PM 834 Setup' applicable claims/services must be adjudicated in order for co-pay/private pay assignment to occur and services to reflect values; 834-determined Co-Pay/Private Pay values will not be immediately reflected in Claim Processing forms during initial service entry or in 837 file compilation/posting reports
5. Following batch/claim/service adjudication - open claims/services for review via 'Claim Processing (UB-04)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
6. Navigate to 'Service Detail' section of form.
7. Select service row and click 'Edit Selected Item'.
8. For Institutional/UB-04 claims/services where applicable Co-Pay/834 Eligibility Assignment entry is defined, ensure that services are assigned 'Member Co-Pay' or 'Private Pay Amount' values as follows:
9. First service within each claim associated to Co-Pay/834 Eligibility Assignment entry is assigned 'Member Co-Pay' or 'Private Pay Amount' from 'How Much Co-Pay to Apply' value defined for service (via Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form/entries and Avatar PM 834 eligibility data)
10. Note - 'Member Co-Pay' or 'Private Pay Amount' assignment is determined by 'Apply as Co-Pay or Private Pay' field in Avatar MSO 'Set Up Co-Pay Based On Avatar PM 834' form; Co-Pay/834 Eligibility Assignment entries should be defined with Co-Pay or Private Pay selected based on which field present in Avatar MSO Claims Processing forms/according to 'Enable Private Pay Amount' Registry Setting
11. Note - Determination of Co-Pay/834 Eligibility Assignment is via 'Co-Pay Indicator Value' comparison to Avatar PM 834 Eligibility Information Health Coverage (2300-HD) or Health Coverage Policy Number (2300-REF) values in Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov' ('eligibility_category' or 'reference_identification' fields, respectively)
12. Subsequent/additional services within each claim are not assigned 'Member Co-Pay' or 'Private Pay Amount' (zero amount)
13. Claims/services where no applicable Co-Pay/834 Eligibility Assignment entry is defined are not assigned 'Member Co-Pay' or 'Private Pay Amount' (zero amount)

1. Open 'Registry Settings' form.
2. Enter search value 'Enable APD Rule for Missing TPL/COB/OHC' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' is returned (under 'Avatar MSO -> Claims Processing' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"If 'Y' is selected the following will be added:

The 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' fields will be added to the 'Approve/Pend/Deny Rules Definition' form.

The 'Medicare Paneled Provider' field will be added to the 'Contracting Provider Registration' form.

The 'Medicare Allowable Procedure Code' field will be added to the 'CPT Code Definition' form.

Selecting 'N' removes the fields and disables the related functionality."

• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Contracting Provider(s) eligible for 'Contracting Provider Registration' entry/update
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Contracting Provider Registration' form.
2. Open Avatar MSO 'Contracting Provider Registration' form.
3. Enter/select Contracting Provider for Contracting Provider Registration entry/edit.
4. Click 'Add' button to create new Contracting Provider Registration (or select existing Contracting Provider Registration record for edit).
5. Ensure that 'Medicare Paneled Provider' field is present in form; select value for 'Medicare Paneled Provider'.
6. 'Medicare Paneled Provider' value will dictate whether claims/services for Contracting Provider are subject to the 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rule in claim processing/service adjudication where Avatar PM 'Medicare' Eligibility Coverage COB information is found for client
7. Enter/select values for all other required/desired fields in 'Contracting Provider Registration' form.
8. Click 'Submit' button to file 'Contracting Provider Registration' form.
9. Open Avatar MSO 'Contracting Provider Registration' form.
10. Enter/select previously filed Contracting Provider Registration record.
11. Ensure that previously selected Yes/No value is present in 'Medicare Paneled Provider' field.
12. Open Crystal Reports or other SQL reporting tool.
13. In Avatar MSO SQL table 'SYSTEM.history_provider_registration', ensure that row is present for information filed via 'Contracting Provider Registration' form, including values for 'medicare_paneled_code' and 'medicare_paneled_value' fields.

• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'CPT Code Definition' form.
2. Select 'Add' or 'Edit' action in 'Add/Edit/Delete CPT Code' field.
3. Enter (or search/select) CPT Code Definition to be added (or updated).
4. Ensure that 'Medicare Allowable Procedure Code' field is present in form; select value for 'Medicare Allowable Procedure Code'.
5. 'Medicare Allowable Procedure Code' value will dictate whether claims/services under selected CPT Code are subject to the 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rule in claim processing/service adjudication where Avatar PM 'Medicare' Eligibility Coverage COB information is found for client
6. Enter/select values for all other required/desired fields in 'CPT Code Definition' form.
7. Click 'File CPT Service Code' button when code entry/edit has been completed.
8. Ensure 'CPT Code Successfully Filed' message dialog is present, and click 'OK' button.
9. Select 'Edit' and open same CPT Service Code record for review.
10. Ensure that previously selected Yes/No value is present in 'Medicare Allowable Procedure Code' field.
11. Open Crystal Reports or other SQL reporting tool.
12. In Avatar MSO SQL table 'SYSTEM.table_cpt_service_codes', ensure that data row is present for information filed via 'Provider Fee Definition' form, including 'medicare_allowable_code' and 'medicare_allowable_value' fields.

• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Approve/Pend/Deny Rules Definition' form.
2. Enter/select Funding Source for Approve/Pend/Deny Rules Definition view/update.
3. Ensure 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' fields are present in form.
4. 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field will dictate how many days prior to 'Date Claim Received' that 'Date of Service' is allowed without Third Party Payment information for service where Avatar PM 'Commercial' and/or 'Medicare' Eligibility Coverage TPL/COB/OHC information is found for client
5. Note - 'Commercial' Eligibility Coverage COB information will be determined by data in Avatar PM Eligibility SQL table SYSTEM.eligibility_dep_cov_cob' where 2320-REF01 Reference Identification Qualifier ('cob_addl_iden_qual') value = '60'(Account Suffix Code) and where 2320-REF02 Reference Identification ('cob_addl_policy_num') value is defined in Avatar MSO Dictionary/Data Element 'TPL Coverage Type Codes - Commercial' ('Other Tabled Files' Indirect, Data Element 90100)
6. Note - 'Medicare' Eligibility Coverage COB information will be determined by data in Avatar PM Eligibility SQL table SYSTEM.eligibility_dep_cov_cob' where 2320-REF01 Reference Identification Qualifier ('cob_addl_iden_qual') value = '60' (Account Suffix Code) and where 2320-REF02 Reference Identification ('cob_addl_policy_num') value is defined in Avatar MSO Dictionary/Data Element 'TPL Coverage Type Codes - Medicare' ('Other Tabled Files' Indirect, Data Element 90101)
7. 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' will dictate claim/service status (Approved/Pended/Denied) in case where 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' allowance is exceeded for claim/services
8. Ensure 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' field is disabled where no value is entered/present in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field.
9. Enter value in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field.
10. Ensure 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' field is enabled and required where value is entered/present in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' field.
11. Select value for 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' field.
12. Enter/select values for any other Approve/Pend Deny Rules Definition fields as required/desired.
13. Click 'Submit' button to file 'Approve/Pend/Deny Rules Definition' form.
14. Re-open Avatar MSO 'Approve/Pend/Deny Rules Definition' form, selecting same/previously filed Funding Source for Approve/Pend/Deny Rules Definition view.
15. Ensure values entered/filed for 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' fields are present in form.
16. Open Crystal Reports or other SQL reporting tool.
17. In Avatar MSO SQL table 'SYSTEM.table_app_pen_den_rules', ensure that data row is present for information filed via 'Approve/Pend/Deny Rules Definition' form, including values for 'days_prior_dt_clm_rvd_tpl', 'no_third_party_prim_code' and 'no_third_party_prim_value' fields.

• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled (with value '2')
• Avatar MSO Registry Setting 'Enable APD Rule for Missing TPL/COB/OHC' must be enabled
• Note - Avatar PM 2023 Update 58 is required for support of the 'Enable APD Rule for Missing TPL/COB/OHC' Registry Setting/functionality
• 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)
• 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)
• Following Avatar MSO Dictionaries/Data Elements must be defined with values from Avatar PM 834 Eligibility Coverage COB Information, using codes from 'Additional Coordination Of Benefits Identifiers' 2320-REF02 (Reference Identification) where 2320-REF01 (Reference Identification Qualifier) = '60' (Account Suffix Code)
• 'TPL Coverage Type Codes - Commercial' ('Other Tabled Files' Indirect, Data Element 90100)
• 'TPL Coverage Type Codes - Medicare' ('Other Tabled Files' Indirect, Data Element 90101)
• 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' and 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' Approve/Pend/Deny Rules must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• Claims/services for Contracting Provider where 'Medicare Paneled Provider' is set to 'Yes' (via Avatar MSO 'Contracting Provider Registration' form)
• Claims/services for CPT Service Code where 'Medicare Allowable Procedure Code' is set to 'Yes' (via Avatar MSO 'CPT Code Definition' form)
• Claims/services for Member/Client with Eligibility Coverage Information in Avatar PM (information in Avatar PM SQL tables 'SYSTEM.eligibility_dependent_cov' and 'SYSTEM.eligibility_dep_cov_cob', for PATID/Subscriber Unique ID)
• Crystal Reports or other SQL reporting tool

1. Enter one or more claims/services in Avatar MSO, using Provider, Funding Source and CPT Code values where Approve/Pend/Deny Rule conditions are defined for claim processing/adjudication.
2. Note - Professional Claim/Service entry using CPT Codes may be done via 'Fast Service Entry'/'Claim Processing (CMS 1500)' forms and '837 Health Care Claim Professional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
3. During or following batch/claim/service entry - 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').
4. Note - If using '837 Health Care Claim Professional' form for 837 compilation/posting, claim processing adjudication status for services may also be reviewed in the 837 Professional Compile/Post report
5. Navigate to 'Service Detail' section of form.
6. Select service row and click 'Edit Selected Item'.
7. For claims/services using Funding Source where 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rule is defined, ensure that claim/service status is adjudicated as follows:
8. Where client has TPL/COB/OHC Eligibility Coverage Information in Avatar PM, 'Commercial' and/or 'Medicare' coverage type will be determined as follows (from information in Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cob' and Avatar MSO 'TPL Coverage Type Codes...' Dictionary Codes):
9. 'Commercial' coverage is determined by Eligibility Coverage Information for Date of Service where Additional Coordination Of Benefits Identifiers 2320-REF01 (Reference Identification Qualifier) = '60' (Account Suffix Code) and 2320-REF02 (Reference Identification) = [Dictionary Code defined for Avatar MSO 'TPL Coverage Type Codes - Commercial' Dictionary]
10. In Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cob', Reference Identification Qualifier = 'cob_addl_iden_qual', Reference Identification = 'cob_addl_policy_num'
11. 'Medicare' coverage is determined by Eligibility Coverage Information for Date of Service where Additional Coordination Of Benefits Identifiers 2320-REF01 (Reference Identification Qualifier) = '60' (Account Suffix Code) and 2320-REF02 (Reference Identification) = [Dictionary Code defined for Avatar MSO 'TPL Coverage Type Codes - Medicare' Dictionary]
12. In Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cob', Reference Identification Qualifier = 'cob_addl_iden_qual', Reference Identification = 'cob_addl_policy_num'
13. For clients determined to have 'Commercial' and/or 'Medicare' TPL/COB/OHC Eligibility Coverage for Date of Service, service must include COB/Third Party Adjudication Information entry to pass the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule
14. Service COB/Third Party Adjudication Information from 837 Professional Other Subscriber Information (2320)/Other Payer Name (2330B)/Line Adjudication Information (2430) loops and/or entered directly in Avatar MSO via 'Enter Third Party Adjudication Data' button in 'Fast Service Entry' and/or 'Claim Processing (CMS 1500)' forms
15. TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny condition applies to services where Date of Service is greater than maximum number of days prior to 'Date Claims Received' value (as defined in 'Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted for TPL/COB/OHC' Approve/Pend/Deny Rules field)
16. For services where Date of Service is less than or equal to maximum number of days prior to 'Date Claims Received' value, TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny condition does not apply/is not enforced
17. For clients determined to have 'Commercial' type TPL/COB/OHC Eligibility Coverage, the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is enforced in claim/service adjudication for all Avatar MSO Contracting Providers and all CPT Codes under Funding Source where rule defined
18. For clients determined to have 'Medicare' type TPL/COB/OHC Eligibility Coverage, the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is enforced in claim/service adjudication only for Avatar MSO Contracting Providers and CPT Codes where the following are true:
19. 'Medicare Paneled Provider' field is set to 'Yes' in applicable 'Contracting Provider Registration' entry
20. 'Medicare Allowable Procedure Code' field is set to 'Yes' for 'CPT Code Definition' entry
21. Where either setup field noted above is set to 'No' or not defined, the TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is not enforced in claim/service adjudication for clients determined to have 'Medicare' type TPL/COB/OHC Eligibility Coverage
22. Ensure that 'Claim Status' field is set to value selected for 'Days Prior to 'Date Claims Received' Exceeded for Claims with TPL/COB/OHC' Approve/Pend/Deny Rules field for services where TPL/COB/OHC Eligibility Coverage Approve/Pend/Deny Rule is enforced and service does not include COB/Third Party Adjudication Information.
23. 'Explanation of Coverage' field will include value 'No COB included with the claim, although primary coverage exists based on 834 eligibility data'

1. Open 'Registry Settings' form.
2. Enter search value 'Allow Provider Fee Definition By Age' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Allow Provider Fee Definition By Age' is returned (under 'Avatar MSO -> System Maintenance -> Provider Fee Definition Maintenance' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"This setting controls the 'Minimum Age', 'Maximum Age' and 'Age on Admission' fields on the 'Provider Fee Definition' form.

The minimum and maximum fields allow users to specify different fees by age range. The 'Age on Admission' field allows the users to specify that the age on the admission date should be used rather than the age on the date of service.

Enter "Y" to have the fields visible on the 'Provider Fee Definition' form. Enter "N" to hide the fields."

• Avatar MSO Registry Setting 'Allow Provider Fee Definition By Age' must be enabled
• CPT Codes/Revenue Codes defined in system for Provider Fee Definition entry
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Provider Fee Definition' form.
2. Select 'Enter New' or 'Edit Existing' action in 'Enter New Or Edit Existing Fee Definition' field.
3. Select Contracting Provider and CPT Service Code/Revenue Code (and select existing fee if using 'Edit Existing' action).
4. Enter value for 'Effective Date' field.
5. Select value for 'Funding Source' field.
6. Ensure the following fields are present in 'CPT Code Definition' form:
7. 'Minimum Age'
8. Dictates client minimum age for Provider Fee to be used/considered (as determined by 'Date of Service' or 'Admission Date' value compared to 'Date of Birth' value for client)
9. 'Maximum Age'
10. Dictates client maximum age for Provider Fee to be used/considered (as determined by 'Date of Service' or 'Admission Date' value compared to 'Date of Birth' value for client)
11. 'Age on Admission'
12. When set to 'No' (or no value selected) - Provider Fee Table entry applicable to service will be determined by client age on the Date of Service (in conjunction with the 'Minimum Age' and 'Maximum Age' Provider Fee Definition criteria fields, as compared to 'Date of Birth' value for client)
13. When set to 'Yes' - Provider Fee Table entry applicable to service will be determined by client age on the Admission Date of associated episode (in conjunction with the 'Minimum Age' and 'Maximum Age' Provider Fee Definition criteria fields, as compared to 'Date of Birth' value for client)
14. Ensure that if value is entered for either 'Minimum Age' or 'Maximum Age', both fields are required.
15. Enter/select values for 'Minimum Age', 'Maximum Age' and 'Age on Admission' fields.
16. Enter/select values for all other Provider Fee Definition fields as desired/required fields.
17. Click 'Submit' button to file Provider Fee Definition record.
18. Ensure user is presented with dialog noting 'Provider Fee Definition has completed. Do you wish to return to form?'; click 'Yes' button to return to form.
19. Select 'Edit Existing' in the 'Enter New Or Edit Existing Fee Definition' field.
20. Select Contracting Provider and CPT Service Code/Revenue Code where Provider Fee Definition previously filed.
21. Click 'Select Fee Definition To Edit' button and select Provider Fee Definition entry for view.
22. Confirm previously entered/filed Provider Fee Definition values are present in form, including values for 'Minimum Age', 'Maximum Age' and/or 'Age At Admission' fields.
23. Open Crystal Reports or other SQL reporting tool.
24. In Avatar MSO SQL table 'SYSTEM.table_prov_fee_byprog', ensure that data row is present for information filed via 'Provider Fee Definition' form, including 'age_min', 'age_max' and ;age_on_admission_code'/'age_on_admission_value' fields.

• Avatar MSO Registry Setting 'Allow Provider Fee Definition By Age' must be enabled
• Avatar MSO Provider Fee Definition Upload File containing one or more valid rows, including values for 'Minimum Age', 'Maximum Age' and 'Age on Admission' (upload file positions 14, 15 and 27 respectively)

1. Open Avatar MSO 'Provider Fee Definition' form.
2. Navigate to 'Provider Fee Definition Upload' section of form.
3. Click 'Select File' button to open file selection dialog; select Provider Fee Upload File for processing.
4. Click 'Process File Upload' button to process upload file and post/file valid rows.
5. Ensure user is presented with dialog noting Provider Fee Definition Upload file records read/records accepted/records rejected counts; click 'OK button to close dialog.
6. Example: '10 Records Read. 8 Records Accepted. 2 Records Rejected'
7. Navigate to 'Provider Fee Definition' section of form (main/first section).
8. Select 'Edit Existing' in the 'Enter New Or Edit Existing Fee Definition' field.
9. Select Contracting Provider and CPT Service Code/Revenue Code where Provider Fee Definition filed via file upload.
10. Click 'Select Fee Definition To Edit' button and select Provider Fee Definition entry for view.
11. Confirm values filed via upload for Provider Fee Definition entry are present in form, including values for 'Minimum Age', 'Maximum Age' and/or 'Age At Admission' fields (upload file positions 14, 15 and 27 respectively).

• Avatar MSO Registry Setting 'Allow Provider Fee Definition By Age' must be enabled
• One or more Provider Fee Definition entries where 'Minimum Age'/'Maximum Age' and 'Age At Admission' are defined
• Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing

1. Enter one or more claims/services in Avatar MSO using Provider, Funding Source and CPT Code/Revenue Code values where Provider Fee Definition entries/rows including 'Minimum Age'/'Maximum Age'/'Age At Admission' are defined in system.
2. 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
3. During or following batch/claim/service entry - 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').
4. Navigate to 'Service Detail' section of form.
5. Select service row and click 'Edit Selected Item'.
6. Ensure 'Total Fee Table Amount' for service(s) is defined by/associated to Provider Fee Definition entries/rows including 'Minimum Age'/'Maximum Age'/'Age At Admission' values as follows:
7. Client Age for service must be equal to or greater than 'Minimum Age' value and equal to or less than 'Maximum Age' value for Provider Fee Definition entry/row to apply to service
8. Where Provider Fee Definition 'Age At Admission' is set to 'No' (or not defined), Client Age for Provider Fee Definition will be determined by 'Date Of Birth' value for client compared to Date of Service
9. Where Provider Fee Definition 'Age At Admission' is set to 'Yes', Client Age for Provider Fee Definition will be determined by 'Date of Birth' value for client compared to Admission Date of associated episode (Client's Age at Admission is used for Provider Fee Definition association regardless of Date of Service)
10. In case where no 'Date of Birth' value is defined for client, Provider Fee Definition entries/rows including 'Minimum Age'/'Maximum Age'/'Age At Admission' values will not be considered/associated to service

1. Open 'Registry Settings' form.
2. Enter search value 'Enable Additional Fields' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable Additional Fields' is returned (under 'Avatar MSO -> System Maintenance -> Claim Processing Blackout' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"If 'Y' is selected the following fields are added to the 'Claim Processing Blackout' form:

'Rule ID'

'Rule Description'

'Performing

Provider'

'Performing Provider Primary License Type'

'CPT Codes'

'Revenue

Codes'

'Diagnosis Codes'

'Funding Sources' (enables selection of multiple Funding Sources)

The 'Blackout Group Order Definition' section

NOTE: This registry setting is a ONE WAY registry setting that can only be enabled. Once turned on, this registry setting cannot be disabled."

• Avatar MSO Registry Setting 'Enable Additional Fields' must be enabled (Avatar MSO -> System Maintenance -> Claim Processing Blackout)
• Following Avatar MSO Dictionaries/Data Elements must be defined:
• 'Blackout Reason' ('Other Tabled Files' Indirect, Data Element 4209)
• 'Blackout Group' ('Other Tabled Files' Indirect, Data Element 4222)
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Claim Processing Blackout' form.
2. Select 'Add' in 'Add/Edit/Delete' field to add new Claim Processing Blackout entry (or select 'Edit' and select existing record for update in 'Blackout Record' field).
3. Where Avatar MSO Registry Setting 'Enable Additional Fields' is enabled, ensure 'Rule ID' and 'Rule Description' fields are present in form (and required).
4. Enter value in 'Rule ID' and 'Rule Description' fields.
5. Where Avatar MSO Registry Setting 'Enable Additional Fields' is enabled, ensure following Claim Processing Blackout criteria/definition fields are present in form:
6. 'Client'
7. 'Provider'
8. 'Funding Sources'
9. Multiple selection format
10. 'Authorization'
11. Populated/available for selection only where value entered/selected in 'Client', 'Provider' or 'Funding Source' field
12. 'Performing Provider'
13. Populated/available for selection only where value entered/selected in 'Provider' field
14. 'Performing Provider Primary License Type'
15. Multiple selection format
16. 'CPT Codes'
17. Multiple selection format
18. 'Revenue Codes'
19. Multiple selection format
20. 'Diagnosis Codes'
21. Multiple selection format
22. 'Blackout Start Date'
23. 'Blackout End Date'
24. 'Authorization Blackout Dates'
25. Multiple selection format; populated with dates covered by 'Authorization' field selection if used
26. 'Claim Status'
27. 'Claim Status Reason'
28. 'Comments'
29. 'Blackout Reason'
30. Populated with selections/values from 'Blackout Reason' Dictionary (Avatar MSO 'Other Tabled Files' Indirect, Data Element 4209)
31. 'Blackout Group'
32. Populated with selections/values from 'Blackout Group' Dictionary (Avatar MSO 'Other Tabled Files' Indirect, Data Element 4222)
33. Used to group Claim Processing Blackout entries for Blackout Group Order Definition
34. Enter/select values in all 'Claim Processing Blackout' form/criteria fields as required/desired.
35. Click 'Submit' button to file Claim Processing Blackout form/record; ensure user is presented with dialog noting 'Claim Processing Blackout has completed. Do you wish to return to form?'
36. Click 'Yes' button to return to 'Claim Processing Blackout' form (or optionally close/re-open form).
37. Select 'Edit' in 'Add/Edit/Delete' field and select previously entered/filed Claim Processing Blackout record in 'Blackout Record' field.
38. Ensure all previously entered/filed Claim Processing Blackout field/criteria entries are present in form.
39. Navigate to 'Blackout Group Order Definition' section of form.
40. Note - If defined, Blackout Group Order will dictate order in which Claim Processing Blackout entries will be checked/performed against claims/services during adjudication (in ascending order according to 'Blackout Group Order' field listing); if Blackout Group Order not defined (or applicable Claim Processing Blackout entry not included in defined Blackout Group/Group Order), Claim Processing Blackout entries will be performed in default order (by ID, using first Claim Processing Blackout entry applicable to service)
41. Select value in 'Blackout Group' field and click 'Add to Order' button to add selected group to 'Blackout Group Order' field/listing
42. Note - 'Place in Order' value may be entered for selected group; doing so will insert in order according to 'Place in Order' value shifting other previous/subsequent entries down/later in order list; if 'Place in Order' value not entered, selected Blackout Group will be added to end of current order
43. Note - Selecting value in 'Blackout Group' field and clicking 'Remove from Order' will remove selected Blackout Group from 'Blackout Group Order' field/listing
44. Repeat Blackout Group selection/order entry as desired.
45. Click 'File Order' button to file/save Blackout Group Order entry/list; ensure user is presented with dialog noting 'Filed successfully.'
46. Click 'OK' button to return to 'Claim Processing Blackout' form, ensuring that previously entered/filed 'Blackout Group Order' list is present in form.
47. Open Crystal Reports or other SQL reporting tool.
48. In Avatar MSO SQL table 'SYSTEM.clm_proc_blackout', ensure row(s) are present for all Claim Processing Blackout entries filed via 'Claim Processing Blackout' form, including values for the following fields: 'rule_id', 'rule_description', 'PPIuniqueid', 'perf_prov_license_code', 'perf_prov_license_shvalue', 'perf_prov_license_value', 'cpt_codes', 'revenue_codes', 'diagnosis_codes', 'funding_sources', 'blackout_group_code' and 'blackout_group_code'.
49. In Avatar MSO SQL table 'SYSTEM.blackout_group_order', ensure that row(s) are present for all Blackout Groups included in 'Blackout Group Order' list entered/filed via 'Claim Processing Blackout' form with 'order' field value.

• Avatar MSO Registry Setting 'Enable Additional Fields' must be enabled (Avatar MSO -> System Maintenance -> Claim Processing Blackout)
• One or more Claim Processing Blackout entries applicable to Client/Provider/Service Dates/Funding Source/CPT or Revenue Codes/Diagnosis Codes must be defined (via Avatar MSO 'Claim Processing Blackout' form)
• Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing
• Crystal Reports or other SQL reporting tool

1. Enter one or more claims/services in Avatar MSO using Provider, Funding Source, CPT/Revenue Codes and Diagnosis Code values where 'Claim Processing Blackout' entry is defined/applicable for claim processing/adjudication.
2. 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
3. During or following batch/claim/service entry - 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').
4. Navigate to 'Service Detail' section of form.
5. Select service row and click 'Edit Selected Item'.
6. Ensure that Claim Processing Blackout entries are evaluated against claim/service information; in case where service information matches Claim Processing Blackout entry information/criteria, ensure that service is set to 'Denied' or 'Pending' state (per 'Claim Processing Blackout' form definition).
7. Claim Processing Blackout entries/services will be evaluated on the following claim/service criteria fields where defined in Claim Processing Blackout entry (with Avatar MSO Registry Setting 'Enable Additional Fields' enabled):
8. Client
9. Provider
10. Funding Source
11. Authorization
12. Performing Provider
13. Performing Provider Primary License Type
14. CPT Codes
15. Revenue Code
16. Diagnosis Code
17. Blackout Start Date (compared to Date of Service)
18. Blackout End Date (compared to Date of Service)
19. Authorization Blackout Dates (compared to Date of Service)
20. Claim Processing Blackout entries will be evaluated against services in order defined by 'Blackout Group Order Definition' if defined (via 'Claim Processing Blackout' form definition); if Blackout Group Order not defined (or applicable Claim Processing Blackout entry not included in defined Blackout Group/Group Order), Claim Processing Blackout entries will be performed in default order (by ID, using first Claim Processing Blackout entry applicable to service)
21. For claims/services where applicable Claim Processing Blackout entry is defined - ensure that 'Claim Status' field is set to value selected for Claim Processing Blackout 'Claim Status' field ('Denied' or 'Pending'); ensure 'Claim Status Reason' field is set to value selected for Claim Processing Blackout 'Claim Status Reason' field.
22. 'Explanation of Coverage' field will include value 'This service occurs during a claim processing blackout'
23. Example: 'The service was denied for the following reason: This service occurs during a claim processing blackout.'
24. In Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail', field 'blackout_id' will reflect Claim Processing Blackout entry applied to service row (linked to 'SYSTEM.clm_proc_blackout.ID')