Avatar MSO Automated Claim Processing and Service Adjudication
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- 837 Health Care Claim Institutional Automated Processing
- 837 Health Care Claim Professional Automated Processing
- Claim Processing Automation
Scenario 1: Automated 837 Inbound Processing/Claim Processing Automation - Verification of 837 Processing
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 and/or Institutional format files for automated processing containing one or more valid claims/services
Steps
- Place multiple 837 Professional and/or Institutional 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 and Institutional 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/837 Institutional 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
• 837 Health Care Claim Institutional
• 837 Health Care Claim Professional
• Claims Processing
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Avatar MSO 'Create Voucher' Form/Function
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
Scenario 1: 'Create Voucher' - Form Verification
Specific Setup:
- One or more service(s) in closed claims processing batch(es) eligible for Voucher inclusion
Steps
- Open Avatar MSO 'Create Voucher' form.
- Note - Acceptance testing may also be confirmed in Vouchers created via Avatar MSO Claim Processing Automation functions
- Select value for 'All or Individual Providers' (and select providers if 'Individual...').
- Enter value for 'Include Services From' and/or 'Include Services Through' date criteria fields (and any other Voucher creation criteria as desired).
- Click 'Submit' button to create Voucher for services within defined date range.
- In Voucher creation confirmation dialog, ensure that values displayed for 'Total Amount of Vouchers Created' and 'Total Number of Vouchers Created' correctly reflect/include all services within 'Include Services From' and 'Include Services Through' date range for EOB(s) included in Voucher.
- In case where an existing process/form session is already currently filing a Voucher - ensure user is presented with an error dialog noting 'Another Create Voucher process is still running. Please try again later' and the Voucher creation process/'Create Voucher' instance is not completed/filed.
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Topics
• Claims Processing
• Create Voucher
• NX
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Avatar MSO '835 Healthcare Claim Payment/Advice' Information
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- 835 Health Care Claim Payment/Advice (MSO)
- 837 Health Care Claim Professional
- CPT Code Definition (MSO)
- Dictionary Update (MSO)
- MSO EOB Message Customization
- Registry Settings (PM)
Scenario 1: '835 Health Care Claim Payment/Advice' - Verification of CAS-2110 Claim Adjustment Reason Code/Remark Code Values
Specific Setup:
- Avatar MSO Registry Setting 'Specify Adjustment (2110-CAS) Logic' must be enabled (with registry value including '3')
- Avatar MSO Registry Setting 'Include Remark Codes (2110-LQ)' may optionally be enabled/disabled
- The following dictionary codes/data elements must be defined (via Avatar MSO 'Dictionary Update' form):
- 'Other Tabled Files' Data Element '(355) Adjustment Reason Code' (including '(357) Default Remark Code (2110-LQ-02)' Extended Dictionary value if utilizing Remark Codes)
- 'Other Tabled Files' Data Element '(357) Default Remark Code' (if utilizing Remark Codes)
- 'Other Tabled Files' Data Element '(351) Adjustment Code' (including '(354) Adjustment Group Code' / '(355) Adjustment Reason Code' / '(356) Adjustment Group Code 5010' Extended Dictionary values)
- 'Adjustment Code'/'Remark Codes' value must be defined for Approve/Pend/Deny Rule 'Missing valid primary CPT Code' adjudication rule (via Avatar MSO 'MSO EOB Message Customization' form)
- CPT Code(s) defined with 'Add On' CPT Code Category (via Avatar MSO 'CPT Code Definition' form)
- EOB record(s) eligible for 835 outbound file inclusion and including service(s) denied due to 'Missing valid primary CPT Code' adjudication rule
Steps
- Open Avatar MSO '835 Health Care Claim Payment/Advice' form.
- Note - Acceptance testing may also be confirmed in 835 files created via Avatar MSO Claim Processing Automation functions
- Select 'Sort File' in the 'Options' field.
- Select 'Contracting Provider' value.
- Select EOB(s) for 835 outbound file inclusion in the 'Select EOB(s)' field - selecting EOB including service(s) denied due to 'Missing valid primary CPT Code' adjudication rule.
- Click 'Process' button.
- Ensure that in case where one or more EOB(s) including services denied due to 'Missing valid primary CPT Code' adjudication rule are selected for 835 sorting, the 'Process' action completes in timely manner, and that '835 Health Care Claim Payment/Advice Report' is displayed following 835 sorting completion.
- In '835 Health Care Claim Payment/Advice Report' results, ensure that Adjustment Group Code, Adjustment Reason Code and Remark Code (if utilized) values defined for the 'Missing valid primary CPT Code' adjudication rule are present for services.
- Close '835 Health Care Claim Payment/Advice Report' report viewer window.
- Select 'Create File On Server' in the 'Options' field.
- Select sorted 835 file in the 'Select File (Date - Time - EOB(s))' field.
- Click 'Process' button.
- Ensure that 835 Health Care Claim Payment/Advice output file is created on server (in output directory defined via Avatar MSO 'Set System Defaults' form).
- In 835 Health Care Claim Payment/Advice file created, ensure that Service Adjustment 2110-CAS Claim Adjustment Group Code/Claim Adjustment Reason Code segments/values are present for services denied due to 'Missing valid primary CPT Code' adjudication rule (and related Health Care Remark Code 2110-LQ segments/values if utilized).
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Topics
• 835 Health Care Claim Payment/Advice
• Claims Processing
• NX
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