Avatar MSO 2023 Update 8

1. Open 'Registry Settings' form.
2. Enter search value 'Enable Authorize and Adjudicate on Per Stay Basis' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' is returned (under 'Avatar MSO -> Care Management -> Service Authorization' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting "Y" adds the 'Authorize and Adjudicate on Per Stay Basis' field to the 'Service Authorization' form. This gives the user the ability to have claims adjudicated on a per stay basis. This means the first service with the authorization number will be approved at the per stay rate and the rest of the services with the same authorization number will be approved for zero dollars.

Select "N" to remove the field and functionality."

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Avatar MSO Registry Setting 'Enable Budget Tracking' may be optionally enabled
• One or more client record(s) eligible for Service Authorization entry
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Service Authorization' form.
2. Note - Acceptance testing may also be confirmed via the Avatar MSO 'Budget Tracking Account Setup' form ('Member Service Authorization' section) where 'Enable Budget Tracking' Registry Setting is enabled
3. Select Client ID for 'Service Authorization' entry.
4. Click 'Add' button in 'Service Authorization' form pre-display to enter new record, or select existing row/record and click 'Edit' button to view/update existing record.
5. Enter/select values for 'Funding Source Authorization Is For', 'Benefit Plan', 'Provider To Be Authorized', 'Begin Date Of Authorization', 'End Date Of Authorization' and 'Current Authorization Status' fields.
6. Ensure 'Authorize and Adjudicate on Per Stay Basis' field is present in form, with 'Yes' and 'No' selections available; select 'Yes' value for 'Authorize and Adjudicate on Per Stay Basis' field.
7. Select 'Individual' in the 'Authorization Grouping Or Individual Authorizations' field.
8. Select 'CPT Code' or 'Revenue Code' in the 'Procedure Code Type' field.
9. Enter search term for CPT Code in 'Code Authorized (1)' field; select CPT Code/Revenue Code in 'Code Authorized (1)' field.
10. Enter value '1' in 'Units Authorized (1)' field.
11. Ensure that if any value other than '1' is entered in 'Units Authorized (1)' field, user is presented with error dialog noting 'Units Authorized (1) must be 1 for a Per Stay Authorization' and the entry is disallowed.
12. Ensure that if 'Group' is selected in 'Authorization Grouping Or Individual Authorizations' field, user is presented with error dialog noting 'Authorization Grouping not allowed for a Per Stay Authorization' and the entry is disallowed.
13. Ensure that on attempted entry/selection of 'Code Authorized (2)' values, user is presented with error dialog noting 'Only one procedure code is allowed for a Per Stay Authorization' and the entry is disallowed.
14. Enter/select values for any other fields in form as required/desired.
15. Click 'Submit' button to file 'Service Authorization' form/record.
16. Following 'Service Authorization' form filing, click 'Yes' button in 'Do you want to return to the Pre-Display?' dialog.
17. Select previously entered/updated Service Authorization row in form pre-display and click 'Edit' button to open.
18. Ensure that previously selected/filed value is present in 'Authorize and Adjudicate on Per Stay Basis' field.
19. Open Crystal Reports or other SQL reporting tool.
20. In Avatar MSO SQL table 'SYSTEM.service_auth_detail', ensure that new fields' per_stay_auth_code'/'per_stay_auth_value' are present and reflect value selected/filed for 'Authorize and Adjudicate on Per Stay Basis' field in 'Service Authorization form.
21. In Avatar MSO SQL table 'SYSTEM.service_auth_detail', ensure that new field 'per_stay_svcuniqueidnew' is present; this field will be populated via Avatar MSO Claim Entry/Claim Processing forms/functions with value linking Service Authorization row/record with Claims Processing Batch ID~Service ID attributed to the first/main per-stay approved/paid service for entry once service(s) have been filed.

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• One or more client record(s) eligible for Service Authorization entry/import
• Avatar MSO 'Service Authorization - Member' Import File containing one or more valid import rows where value is defined for 'Authorize and Adjudicate on Per Stay Basis' (field/segment 441)

1. Open 'File Import' form in Avatar Cal-PM.
2. Select File Type '[Avatar MSO] Service Authorization - Member'.
3. Click 'Process Action' button.
4. Select Avatar MSO Service Authorization - Member import file and click 'Open' button.
5. Select 'Compile/Validate File' in 'Action' field.
6. Select loaded import file and click 'Process Action' button.
7. Ensure that 'Compile/Validate File' action completes, and message 'Compiled' or '(File Name) contains one or more errors. These errors can be reviewed using 'Print Errors' action' is displayed.
8. Click 'OK' button.
9. Select 'Post File' in 'Action' field.
10. Select compiled Avatar MSO Service Authorization - Member import file and click 'Process Action' button.
11. Ensure that 'Post' action completes, and message 'Posted' and/or 'The selected file contains one or more lines with compilation errors. Only those lines without compilation errors will be posted' is displayed.
12. Select 'Print Errors' in 'Action' field for compiled import file with one or more errors.
13. Select compiled import file with any errors and click 'Process Action' button.
14. In '[Avatar MSO] Service Authorization - Member' File Import Error report, ensure that all invalid/errored import row(s) where 'Authorize and Adjudicate on Per Stay Basis' is defined as 'Y' and 'Units Authorized' is not defined as '1' or more than one 'Code Authorized' entry exists are included in report with segment/value reference and error message detail.
15. File Import Error examples:
16. 'Units Authorized (1) must be 1 for a Per Stay Authorization'
17. 'Only one procedure code is allowed for a Per Stay Authorization'
18. Open Avatar MSO 'Service Authorization' form.
19. Select Client ID for 'Service Authorization' view/edit where File Import record/row posted.
20. Select Service Authorization row/record filed via File Import in form pre-display and click 'Edit' button to open.
21. Ensure that imported/filed value is present in 'Authorize and Adjudicate on Per Stay Basis' field.

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'

1. Enter two or more claims/services in Avatar MSO, where services are associated to single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
2. Note - Manual claim/service entry may be done via 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms (in addition to 837 inbound file posting)
3. Adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, nightly automatic adjudication process and/or 'Close Batch' function).
4. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values may not be immediately reflected in Claim Processing forms during initial service entry
5. 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').
6. Navigate to 'Service Detail' section of form.
7. Select service row and click 'Edit Selected Item'.
8. For claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
9. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
10. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
11. Applies to services associated to same/single Service Authorization in same or different claims and/or in same or different Claim Processing batch(es)
12. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
13. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
14. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Client with eligible Service Authorization record(s) valid for 837 Professional inbound file Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
• 837 Health Care Claim Professional file(s) for compilation/posting including one or more valid claims/services

1. Open Avatar MSO '837 Health Care Claim Professional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Professional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
6. Click 'Process' button.
7. In 837 Professional Compile Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
8. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values will not be immediately reflected in 837 Professional Compile/Post Report information
9. Select 'Post File' in the 'Options' field.
10. Select compiled 837 Professional format file and click 'Process' button.
11. In 837 Professional Post Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
12. Avatar MSO Claim Processing batch(es) created for 837 Professional format claims/services will be adjudicated following file posting (and may also be adjudicated via 'Manual Batch Adjudication' form and/or 'Close Batch' function)
13. Following 837 Professional format inbound file claim/service posting and batch/claim/service adjudication, open claims/services for review via 'Claim Processing (CMS 1500)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
14. Navigate to 'Service Detail' section of form.
15. Select service row and click 'Edit Selected Item'.
16. For 837 Professional/CMS 1500 claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
17. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
18. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
19. Applies to services associated to same/single Service Authorization in same or different 837 Professional files, in same or different claims and/or in same or different Claim Processing batch(es)
20. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
21. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
22. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• Client with eligible Service Authorization record(s) valid for 837 Institutional inbound file Service Entry/Claim Processing, where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'
• 837 Health Care Claim Institutional file(s) for compilation/posting including one or more valid claims/services

1. Open Avatar MSO '837 Health Care Claim Institutional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Institutional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
6. Click 'Process' button.
7. In 837 Institutional Compile Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
8. Note - The 'Authorize and Adjudicate on Per Stay Basis' claim processing/service adjudication functionality occurs within the system batch/claim adjudication process. Avatar MSO Claim Processing batch(es) containing Per-Stay claims/services must be adjudicated in order for Per-Stay Adjudication to occur and services to reflect conditional Per-Stay zero dollar adjudication 'Expected Disbursement' and 'Approved Units' values; Disbursement values will not be immediately reflected in 837 Institutional Compile/Post Report information
9. Select 'Post File' in the 'Options' field.
10. Select compiled 837 Institutional format file and click 'Process' button.
11. In 837 Institutional Post Report - ensure that one or more claims/services are compiled and associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes'.
12. Avatar MSO Claim Processing batch(es) created for 837 Institutional format claims/services will be adjudicated following file posting (and may also be adjudicated via 'Manual Batch Adjudication' form and/or 'Close Batch' function)
13. Following 837 Institutional format inbound file claim/service posting and 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').
14. Navigate to 'Service Detail' section of form.
15. Select service row and click 'Edit Selected Item'.
16. For 837 Institutional/UB-04 claims/services associated to same/single Service Authorization where 'Authorize and Adjudicate on Per Stay Basis' is set to 'Yes', ensure that services are adjudicated as follows:
17. First service associated to Per-Stay Service Authorization is adjudicated with 'Approved' claim status and 'Expected Disbursement' amount/Per-Stay rate is full Provider Fee defined for service (via Avatar MSO 'Provider Fee Definition' form/entries) (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
18. Subsequent services associated to Per-Stay Service Authorization are adjudicated with 'Approved' claim status, an 'Expected Disbursement' amount of zero ($0.00) and 'Approved Units' equal to '1' (Subject to all other defined/applicable Approve/Pend/Deny Rules and 837 Claim Processing settings)
19. Applies to services associated to same/single Service Authorization in same or different 837 Institutional files, in same or different claims and/or in same or different Claim Processing batch(es)
20. 'Explanation of Coverage' field will include value 'Included in per stay rate - approved at zero dollars.'
21. In case where first service associated to Per-Stay Service Authorization is adjudicated with 'Denied' claim status (or is deleted prior to closing), subsequent services associated to same Service Authorization are adjudicated with 'Denied' claim status
22. 'Explanation of Coverage' field will include value 'Included in per stay rate - authorized service denied or missing.'

• Avatar MSO Registry Setting 'Enable Authorize and Adjudicate on Per Stay Basis' must be enabled
• One or more services in 'Closed' status Claim Processing batch(es) eligible for Retro Claim Adjudication entry, associated to Service Authorization record(s) where 'Authorize and Adjudicate on Per Stay Basis' field is set to 'Yes'

1. Open Avatar MSO 'Retro Claim Adjudication' form.
2. Note - Acceptance testing may also be confirmed via 837 Health Care Claim Professional/Institutional 'Void' and/or 'Replacement' Retro Claim Adjudication entries and/or '[Avatar MSO] Retro Claim Adjudication' File Import
3. Select 'Add' in the 'Add/Edit/Delete Claim Adjudication' field.
4. Select 'Claim' and 'Date of Service/Procedure' values for Retro Claim Adjudication entry/update, selecting service which is first service associated to Per-Stay Service Authorization (service which was Approved with 'Expected Disbursement' value from full Provider Fee Definition).
5. On selection of first service associated to Per-Stay Service Authorization, ensure user is presented with an alert dialog noting 'The selected Procedure is the primary Per Stay Procedure. If Updated Approved Units are set to zero then all other procedures in the Stay will be updated to have zero Updated Approved Units also.'
6. Enter zero value for 'Updated Approved Units' and allow system calculation of updated values or directly set 'Take Back Units' and 'Updated Disbursement Amount' values for service (so that Retro Claim Adjudication entry is full service takeback/void entry).
7. Select value for 'Adjustment Code' field if not defaulted automatically.
8. Click 'Update Claim Adjudication' button in 'Retro Claim Adjudication' form to file entry/update.
9. On entry/filing of full takeback/void Retro Claim Adjudication for first service associated to Per-Stay Service Authorization - ensure that additional Retro Claim Adjudication entries are automatically created in system for all other Per-Stay services in 'Closed' status batches associated to same Service Authorization, with 'Updated Approved Units' set to zero.
10. Applies to services associated to same/single Service Authorization in same or different claims and/or in same or different Claim Processing batch(es)
11. 'Comments' field for additional/automatically created Retro Claim Adjudication entries will include value 'Included with Per Stay Service.'
12. Retro Claim Adjudication entries created for additional/secondary claims/services associated to Per-Stay Service Authorization may be confirmed via 'Retro Claim Adjudication' form 'Edit' selection (or reviewed directly via Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications')