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Avatar MSO 2024 Monthly Release 2024.00.00 Acceptance Tests

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Update 1 Summary | Details
2024 Update installation
Scenario 1: Validate Upgrading Avatar MSO 2023 to 2024 is successful when 2023.04.00 is loaded
Specific Setup:
  • Latest Monthly Release is installed.
Steps
  1. Open the "Product Updates" form.
  2. Select the appropriate [Namespace] from the Application dropdown list
  3. Click [Select Update/Customization Pack].
  4. Browse to the location for the updates and select the Update 1.
  5. Click [OK] on the "File Upload Complete" window.
  6. Click [Review Update/Customization Pack Contents].
  7. Verify Update 1 is included.
  8. Click [Install Update/Customization Pack].
  9. Click [OK] when the install completes.
  10. Click [Close Form].
Topics
• Upgrade
Update 2 Summary | Details
Avatar MSO 'Fast Service Entry' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Approve/Pend/Deny Rules Definition
  • Fast Service Entry
Scenario 1: 'Fast Service Entry' - Verification of 'Number of Services Per Claim Allowed' Adjudication Rule
Specific Setup:
  • Field 'Number of Services Per Claim Allowed' in Avatar MSO 'Approve/Pend/Deny Rules Definition' form must be defined
  • Field 'Number of Services Per Claim Allowed Exceeded' in Avatar MSO 'Approve/Pend/Deny Rules Definition' form must be defined
  • Two or more client records eligible for claim/service entry
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
  2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
  6. Enter/select values in all other service detail fields in form as required/desired.
  7. Click 'Add New Item' button.
  8. Enter/select service entry information values, using different/distinct Client ID in the 'Member Name or ID' field.
  9. Select value for 'Authorization Number' field.
  10. Ensure that in case where 'Member Name or ID' differs between service rows entered in 'Fast Service Entry' form, services not exceeding the 'Number of Services Per Claim Allowed' setting are not incorrectly denied with adjudication reason 'Number of services per claim allowed exceeded' in case where services for different/distinct clients do not exceed limit.
  11. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
  12. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
Avatar MSO 'Approve/Pend/Deny Rules Definition' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Approve/Pend/Deny Rules Definition
Scenario 1: 'Approve/Pend/Deny Rules Definition' - Form Verification
Specific Setup:
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO 'Approve/Pend/Deny Rules Definition' form.
  2. Select Funding Source for Approve/Pend/Deny Rules Definition entry/edit.
  3. Ensure the following fields are present in the 'Approve/Pend/Deny Rules Definition' form:
  4. 'Rule Coverage Period'
  5. Dropdown selection field including existing A/P/D Rule Coverage Periods as well as 'Create New' selection
  6. On installation of Avatar MSO 2024 Update 2, a default A/P/D Rule Coverage Period entry with 'Start Date' of '1/1/1990' and no 'End Date' value is defined for each/all Funding Sources based on Approve/Pend/Deny Rules Definition information existing prior to update (to allow for Claim Processing/Service Adjudication under same A/P/D Rule conditions as defined prior to update for all services).
  7. 'Start Date'
  8. Start Date for A/P/D Rule Coverage Period (required); services with 'Date of Service' on or after this date will be adjudicated according to A/P/D rules defined for this Rule Coverage Period
  9. 'End Date'
  10. End Date for A/P/D Rule Coverage Period; services (not required); if defined, services with 'Date of Service' on or before this date will be adjudicated according to A/P/D rules defined for this Rule Coverage Period
  11. If 'End Date' is not defined, A/P/D Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  12. Select existing A/P/D Rule Coverage Period for edit/review, or select 'Create New' for new A/P/D Rule Coverage Period entry.
  13. Enter value for 'Start Date' field (and 'End Date' if desired).
  14. Enter/select values for all Approve/Pend/Deny Rule fields/settings as required/desired.
  15. Click 'Submit' button to file Approve/Pend/Deny Rules Definition' form/Rule Coverage Period information.
  16. In case where Rule Coverage Period 'Start Date'/'End Date' values overlap another Rule Coverage Period defined for the same Funding Source - Ensure that user is presented with an error dialog noting 'Date ranges are overlapping, please adjust dates appropriately', submission/filing is canceled and user is returned to form to correct overlapping dates
  17. In case where Rule Coverage Period 'End Date' value is prior to 'Start Date' value - Ensure that user is presented with an error dialog noting 'End Date needs to be the same day or later than Start Date', submission/filing is canceled and user is returned to form to correct invalid dates
  18. Re-open 'Approve/Pend/Deny Rules Definition' form.
  19. In 'Rule Coverage Period', ensure all previously entered/filed Rule Coverage Periods are available for selection.
  20. Select existing A/P/D Rule Coverage Period for edit/review.
  21. Ensure that previously entered/selected values for all Approve/Pend/Deny Rule fields are present in form for selected A/P/D Rule Coverage Period.
  22. Open Crystal Reports or other SQL reporting tool.
  23. In Avatar MSO SQL table 'SYSTEM.apd_rule_def', ensure that Approve/Pend/Deny Rule field values/information are present for all A/P/D Rule Coverage Periods entered/filed in Avatar MSO.
  24. Note - Avatar MSO SQL table 'SYSTEM.table_app_pen_den_rules' is no longer used for storage of 'Approve/Pend/Deny Rules Definition' form information and will not reflect/include any information filed after Avatar MSO 2024 Update 2 installation; all updated/added 'Approve/Pend/Deny Rules Definition' form information will be filed/stored in Avatar MSO SQL table 'SYSTEM.apd_rule_def'
Avatar MSO 'Approve/Pend/Deny Rules Definition' Claim Processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Approve/Pend/Deny Rules Definition
  • 837 Health Care Claim Institutional
  • Claim Processing (UB-04)
  • Fast Service Entry
  • Fast Service Entry Submission
Scenario 1: '837 Health Care Claim Professional' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • 837 Health Care Claim Professional file with one or more valid claims
Steps
  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 successfully compiled.
  8. Select 'Post File' in the 'Options' field.
  9. Select compiled 837 Professional format file and click 'Process' button.
  10. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  11. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  12. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  13. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  14. Examples:
  15. 'The service was approved with the following notices: Maximum Number Of Units Of Procedure Code Per Day Exhausted. Invalid Measurement Code for Procedure Code. Location's Place of Service Is Invalid For Procedure Code. Limited by total charge'
  16. 'The service was denied for the following reasons: Specified Duration is not valid for Procedure Code. Invalid Measurement Code for Procedure Code. The service also has the following Approval notices: Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Claim Submitted with a Date Range'
  17. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  18. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
  19. Note - Select claim processing/service adjudication Approve/Pend/Deny rules/functionality occurs within the system batch/claim adjudication process (and not in 837 inbound file compilation/posting). Avatar MSO Claim Processing batch(es) must be adjudicated following 837 file posting in order for services to reflect all Approve/Pend/Deny rules/adjudication 'Explanation of Coverage', 'Expected Disbursement' and 'Approved Units' values
Scenario 2: '837 Health Care Claim Institutional' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • 837 Health Care Claim Institutional file with one or more valid claims
Steps
  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 successfully compiled.
  8. Select 'Post File' in the 'Options' field.
  9. Select compiled 837 Institutional format file and click 'Process' button.
  10. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  11. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  12. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  13. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  14. Examples:
  15. 'The service was approved with the following notices: Maximum Number Of Units Of Procedure Code Per Day Exhausted. Invalid Measurement Code for Procedure Code. Location's Place of Service Is Invalid For Procedure Code. Limited by total charge'
  16. 'The service was denied for the following reasons: Specified Duration is not valid for Procedure Code. Invalid Measurement Code for Procedure Code. The service also has the following Approval notices: Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Claim Submitted with a Date Range'
  17. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  18. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
  19. Note - Select claim processing/service adjudication Approve/Pend/Deny rules/functionality occurs within the system batch/claim adjudication process (and not in 837 inbound file compilation/posting). Avatar MSO Claim Processing batch(es) must be adjudicated following 837 file posting in order for services to reflect all Approve/Pend/Deny rules/adjudication 'Explanation of Coverage', 'Expected Disbursement' and 'Approved Units' values
Scenario 3: 'Claim Processing (HCFA 1500)' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Enter one or more claims/services in Avatar MSO using Funding Source where one or more Approve/Pend/Deny Rule Coverage Period(s) are defined in system.
  2. Note - Claim/Service entry may be done via 'Fast Service Entry'/'Claim Processing (CMS 1500)' forms and/or '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)' (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 Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  7. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  8. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  9. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  10. Examples:
  11. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
  12. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
  13. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  14. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
Scenario 4: 'Claim Processing (UB-04)' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Enter one or more claims/services in Avatar MSO using Funding Source where one or more Approve/Pend/Deny Rule Coverage Period(s) are defined in system.
  2. Note - Claim/Service entry may be done via 'Claim Processing (UB-04)' form and/or '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 (UB-04)' (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 Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  7. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  8. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  9. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  10. Examples:
  11. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
  12. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
  13. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  14. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
Scenario 5: 'Fast Service Entry' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
  2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
  6. Enter/select values in all other service detail fields in form as required/desired.
  7. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  8. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  9. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  10. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  11. Examples:
  12. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
  13. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
  14. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  15. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
  16. On editing one or more service detail field values related to claim adjudication/status (including 'Date of Service') - ensure that 'Claim Status'/'Explanation of Coverage' information is re-processed using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (and claim/service adjudication status and information updated accordingly).
  17. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
  18. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
Avatar MSO 'Fast Service Entry' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Fast Service Entry
Scenario 1: 'Fast Service Entry' - Form Verification
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Contracting Provider Program' must be enabled
  • CPT Code where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included (via Avatar 'Provider Fee Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
  2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', and 'Contracting Provider Program' fields.
  6. Select value in 'Procedure Code' field, selecting CPT Code where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included.
  7. Ensure that in case where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included for the selected CPT Code/Procedure Code, user is not incorrectly presented with dialog noting 'Procedure Not On Fee Schedule'.
  8. Enter/select values in 'Total Charge', 'Service Units' and 'Authorization Number' fields, as well all other service detail fields as required/desired.
  9. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
  10. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
Avatar MSO to Avatar Cal-PM Parent System Service Filing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Client Ledger
Scenario 1: 'Close Batch' - Avatar MSO to Cal-PM Parent System Service Filing, Verification of Service Filing With Fee Override Enabled for Services with Other Healthcare Coverage Information
Specific Setup:
  • Avatar Cal-PM Parent System is required for Acceptance Testing with Registry Setting 'Support MSO Other Healthcare Coverage' enabled
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
  • Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (set to '1','2', '3' or '4')
  • If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
  • 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
  • CPT Code/Revenue Code must be selected/included for Fee Override in filing to parent system (via Avatar 'Provider Fee Definition' form)
  • One or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
Steps
  1. Open Avatar MSO 'Close Batch' form.
  2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
  3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system.
  4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
  5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
  6. Open 'Client Ledger' form in parent Avatar Cal-PM system.
  7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
  8. Select 'Claim/Episode/All Episodes' value.
  9. Select 'Ledger Type' value.
  10. Click 'Process' button.
  11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
  12. For services originating via Avatar MSO and filed to Avatar Cal-PM parent system (where Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' and Avatar MSO Registry Setting 'Enable Fee Override in PM' are enabled):
  13. Services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM Client Ledger 'Charge' value for service(s) reflects the 'Allowed Amount' value (or 'Expected Disbursement' value if differing) from Avatar MSO Other Healthcare Coverage information for service(s)
  14. Note - In case where PM Service Fee Table Amount is selected for parent system service filing, services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information will use Avatar MSO Allowed Amount/Expected Disbursement service value for Cal-PM parent service 'Cost of Service'/'Guarantor Liability' (to ensure correctly balanced Avatar Cal-PM outbound 837 claim information where Other Healthcare Coverage information is included in original claim/service)
  15. Note - Avatar Cal-PM 'Cost of Service'/'Guarantor Liability' value for service(s) originating in Avatar MSO with Other Healthcare Coverage information will reflect Client Ledger Charge/Allowed Amount/Expected Disbursement value not including Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM
  16. Services not including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM 'Charge'/'Cost Of Service' (as well as 'Guarantor Liability') value for service(s) in Avatar Cal-PM reflects the selected/applicable Avatar MSO Fee Override Type (Expected Disbursement/Fee Table Amount/Total Charge), or PM Service Fee Table Amount where override not selected
Topics
• Claims Processing • Approve/Pend/Deny Rules Definition • 837 Health Care Claim Professional • 837 Health Care Claim Institutional • Registry Settings • MSO To Parent System Integration Mapping
Update 3 Summary | Details
Claims Processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Institutional
  • Look Up Client
  • Treatment pre-display
Internal Test Only
Create EOB
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • State Form Configuration Grid
Internal Test Only
Topics
• 837 Professional • 837 Institutional • Claims Processing • Create EOB • NX
Update 4 Summary | Details
Claims Adjudication Rule Definition - Limit Rule Definition
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Claims Adjudication Rules Definition
Scenario 1: 'Claims Adjudication Rules Definition' - Verification of Limit Rule Filing
Specific Setup:
  • CPT Code Definition and/or Revenue Code Definition are created or an existing CPT Code Definition and/or Revenue Code Definition are identified. Note the cpt codes/ revenue codes.
  • An existing funding source is identified. Note the funding source code/value.
Steps
  1. Open Avatar MSO 'Claims Adjudication Rules Definition' form.
  2. Select 'Add' in 'Action' field (or 'Edit' to select/view/edit existing rule).
  3. Enter/select values for Rule Definition fields 'Rule ID', 'Rule Description', 'Status', 'Status Reason', 'Funding Source' (and 'From Date'/'Through Date' if desired).
  4. Select 'Limit' in 'Rule Type' field.
  5. Verify the 'For Diagnosis' field is exist and enabled.
  6. Select desired diagnosis code in the field.
  7. Verify that the selected diagnosis populated correctly in the field.
  8. Enter/select all required values for 'Limit Rule' Definition fields.
  9. Click 'Add Rule' button to save Limit Rule Definition information.
  10. Ensure Limit Rule Definition information is displayed in 'Business Rule Viewer' field.
  11. Click [Submit].
  12. Ensure confirmation dialog noting 'Claims Adjudication Rules Definition has completed. Do you wish to return to form?' is presented.
  13. Click [Yes].
  14. Select 'Edit' in 'Action' field and select previously entered/filed 'Limit' Type Claims Adjudication Rule for review.
  15. Ensure previously entered/filed Limit Rule Definition information is displayed in 'Business Rule Viewer' field, including CPT Code/Revenue Code where dash character ('-') is used in code.
  16. Select 'Add' option from the 'Action' field.
  17. Select 'Comparison' rule type.
  18. Verify the 'For Diagnosis' field does not exist.
  19. Select 'Existence' rule type.
  20. Verify the 'For Diagnosis' field does not exist.
  21. Click [Discard].
Scenario 2: 'Claims Adjudication Rules Definition' - Verification of Limit Rule Removal
Specific Setup:
  • An existing claim adjudication rule definitions are identified or new definitions are created.
Steps
  1. Open Avatar MSO 'Claims Adjudication Rules Definition' form.
  2. Select 'Add' in 'Action' field (or 'Edit' to select/view/edit existing rule).
  3. Enter/select values for Rule Definition fields 'Rule ID', 'Rule Description', 'Status', 'Status Reason', 'Funding Source' (and 'From Date'/'Through Date' if desired).
  4. Select 'Limit' in 'Rule Type' field.
  5. Enter/select values for Limit Rule Definition fields - including value for ICD-10 Diagnosis Code in 'For Diagnosis' field (if entering new rule).
  6. Click 'Add Rule' button to save Limit Rule Definition information (if entering new rule).
  7. Ensure entered/existing Limit Rule Definition information is displayed in 'Business Rule Viewer' field, including 'For Diagnosis' value/code.
  8. Click 'Remove Selected Item' button to open rule removal selection dialog.
  9. Select Limit Rule Definition row for removal, and click 'OK' button.
  10. Ensure Limit Rule Definition is removed from rule and is not displayed in 'Business Rule Viewer' field.
Topics
• Claims Processing • NX
2023 Update 42 Summary | Details
Avatar MSO - application mappings
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Application Namespace Connections Validation
Scenario 1: Avatar MSO - Validate the migration of global entries in the "^NTSTMAP" Global to the "^RADplusMap" Global
Steps
  1. Internal Testing Only
Scenario 2: Application Namespace Connection Validation
Specific Setup:
  1. Have a system with one or more child namespaces. For example: "PM" or "CWS" namespaces
  2. Have a system that the following modules installed in the system: "Avatar Data Warehouse", " Avatar CWS State Forms" or "Avatar ProviderConnect NX 2023 " and any other desired modules
Steps
  1. Open form "Applications Namespace Connection Validations"
  2. Validate "Currently Connected Namespaces" text box lists the expected child applications and namespace(s):
  3. Validate "Currently Connected Namespaces" text box indicates there are no application namespace connection or mapping errors.
  4. Click [Process]
  5. Validate the "Application Namespace Connections Validation" report list the expected connected child applications and namespace(s)
  6. Validate "Currently Connected Namespaces" text box indicates there are no application namespace connection or mappings errors.
Topics
• Forms
2023 Update 43 Summary | Details
File Import - MSO service authorizations
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • CPT Code Definition (PM)
  • Funding Source Registration
  • Applying Contracting Provider
  • Contracting Provider Registration
  • Financial Eligibility
  • File Import
  • Budget Tracking Account Setup
  • Contracting Provider Service Authorization
Scenario 1: File Import - [Avatar MSO] Service Authorization - Member - No Claimed Services
Specific Setup:
  • Member has an authorized service record that has no claimed services. Note the 'Provider To Be Authorized' value.
  • Create a File Import that will edit the contracting provider. The 'File Type' is [Avatar MSO] Service Authorization - Member'.
  • The value of the 'Provider To Be Authorized' in position seven of the file, must be different from the value noted above.
  • The File Import Mapping guide is included in the update zip file.
Steps
  1. Open 'File Import'.
  2. Select '[Avatar MSO] Service Authorization - Member in 'File Type'.
  3. Select 'Upload New File' in 'Action'.
  4. Click [Process Action].
  5. Select the file.
  6. Click [Open].
  7. Select 'Compile/Validate File' in 'Action'.
  8. Select the file in 'File(s)'.
  9. Click [Process Action].
  10. Verify the file compiles successfully.
  11. Click [OK].
  12. Select 'Print File' in 'Action'.
  13. Select the file in 'File(s)'.
  14. Click [Process Action].
  15. Validate that the report ''Provider To Be Authorized'' field contains the value of the 'Provider To Be Authorized' in position seven of the file.
  16. Close the report.
  17. Select 'Post File' in 'Action'.
  18. Select the file in 'File(s)'.
  19. Click [Process Action].
  20. Verify the file posted successfully.
  21. Click [OK].
  22. Open 'Service Authorization' for the member.
  23. Verify the member service authorization contains same data as the file import file.
  24. Validate that 'Provider' contains the edited value of the 'Provider To Be Authorized', from position seven of the file.
  25. Close the form.
Scenario 2: File Import - [Avatar MSO] Contracting Provider Service Authorization - Verification of Import with Budget Tracking Accounts Enabled
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Budget Tracking' must be enabled (setting 'YA' or 'YC').
  • Avatar MSO 'Contracting Provider Service Authorization' Import file where Budget Tracking 'Account'/'Account Level Begin Date' values/fields are populated (import file segments 13/14).
Steps
  1. Open 'File Import' form in Avatar PM.
  2. Select File Type '[Avatar MSO] Service Authorization - Contracting Provider'.
  3. Click 'Process Action' button.
  4. Select Avatar MSO 'Contracting Provider Service Authorization' import file and click 'Open' button.
  5. Select 'Compile/Validate File' in 'Action' field.
  6. Click 'Process Action' button.
  7. Ensure that 'Compile/Validate File' action is completed, and user is presented with dialog noting compile completion (and file errors where present in compilation).
  8. Select 'Print Errors' in 'Action' field.
  9. Select loaded and compiled 'Contracting Provider Service Authorization' import file.
  10. Click 'Process Action' button.
  11. In 'File Import Error' report, ensure that in case where Budget Tracking 'Account'/'Account Level Begin Date' values/fields are populated (import file segments 13/14) and 'Total Estimated Liability' value/field is not populated (import file segment 21), import row is not compiled and is included in error report with message 'Missing Total Estimated Liability'.
  12. Select 'Print File' in 'Action' field.
  13. Click 'Process Action' button.
  14. In 'Contracting Provider Service Authorization Import' report, ensure that all valid import row(s) are successfully compiled, and record data is correct (including rows where 'Account'/'Account Level Begin Date' and 'Total Estimated Liability' fields/values are populated).
  15. Select 'Post File' in 'Action' field.
  16. Select loaded and compiled 'Contracting Provider Service Authorization' import file.
  17. Click 'Process Action' button.
  18. Ensure that 'Post File' action is completed, and user is presented with dialog noting post completion.
  19. Open 'Contracting Provider Service Authorization' form.
  20. Select imported/posted Contracting Provider Service Authorization record from pre-display.
  21. Ensure that all valid import row(s) for new or updated Contracting Provider Service Authorization records are correct and complete (including values for 'Account' and 'Total Estimated Liability' fields).
  22. Close the form.
Electronic Billing - "Add Support For The Input Of Third Party Payer Amounts" is set to 2
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Contracting Provider Registration
  • Financial Eligibility
  • Client Ledger
  • Electronic Billing
Scenario 1: Electronic Billing - Adjudication or Payment Date validation in DTP*573 - when the registry setting 'Add Support For The Input Of Third Party Payer Amounts'=2
Specific Setup:
  • Registry Settings:
  • The 'Support MSO Other Healthcare Coverage' is set to 'Y'.
  • The 'Add Support For The Input Of Third Party Payer Amounts' set to '2'.
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantor’s code/name.
  • The 'Bill As Primary Guarantor (837/UB92)' is set to No.
  • Another existing guarantor is identified. Note the submitter id populated for the guarantor to be used in the 837 inbound file.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • An admission diagnosis record is created for the client.
  • CPT Code Definition:
  • An existing CPT code is identified, or a new CPT code is created. Note the CPT code/description.
  • Funding Source Registration:
  • An existing funding source is identified, or a new funding source is created. Note the funding source name.
  • Plan Definition:
  • A plan definition is created, or an existing plan is identified. Note the plan id/name.
  • Contracting Provider Registration:
  • A new contracting provider is created, or an existing contracting provider is updated. Note the contracting provider number, name and submitter id to be used in the 837 inbound file.
  • Provider Fee Definition:
  • A fee definition is created. Note the fee definition.
  • MSO to Parent System Integration Mapping:
  • Create mapping for Provider, staff, program, CPT codes and Revenue Codes.
  • Member Specific Information:
  • Create a member specific record. Note the policy number to be used in the 837 inbound file.
  • Service Authorization:
  • Create a new service authorization covering a CPT code created above. Note the authorization number to be used in the 837 inbound file.
  • Set System Defaults (MSO):
  • Set the 'Output Directory text' field to the path where the 837 inbound file will be located.
  • The '837 Custom Prefix to Identify Client ID in 2010BA-NM1-09' is set to desired value. Note the value. The same value to be used in the 837 inbound file before client id. (i.e. NM1*IL*1*TEST*ELEVEN*A***MI*MSO934~).
  • An inbound 837 professional/ institutional file containing the Remaining Patient Liability Amount segment is created and stored to the specific location. Note the path of the file location.
Steps
  1. Open the '837 Health Care Claim Professional' or '837 Health Care Claim Institutional' form.
  2. Load an inbound 837 Professional/ institutional file containing the Remaining Patient Liability Amount segment.
  3. Verify the file loads successfully.
  4. Compile the recently loaded file.
  5. Verify the file compiles successfully.
  6. Verify the report generates successfully.
  7. Review the report.
  8. Verify that the services included in the file are approved.
  9. Post the file.
  10. Verify the file posted successfully.
  11. Open the 'Client Ledger' form.
  12. Verify the services from MSO displays correctly with the '*' next to them.
  13. Close the client ledger.
  14. Open the 'Close Charges'.
  15. Close the charges distributed to the client/guarantor.
  16. Open the 'Electronic Billing' form.
  17. Compile an 837 professional/institutional bill for the time period that covers the services rendered to the client.
  18. Verify the 837 bill compiles successfully.
  19. Dump the file.
  20. Review the file.
  21. Verify in the 837 file have SVD and CAS segments producing with the correct date in the DTP*573 segment. Please note if the adjudication payment date is missing from the OHC table, the DTP*573 segment is displays with a '18401231' date.
  22. Close the file.
  23. Close the form.
Funding Source/Guarantor Mapping - Update Namespace for All Mappings
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Funding Source/Guarantor Mapping
Scenario 1: Funding Source - Guarantor Mapping validation
Specific Setup:
  • An existing funding source is identified, or a new funding source is created. Note the funding source code/value.
Steps
  1. Open the 'Funding Source/Guarantor Mapping' form.
  2. Set the 'Select Funding' to an existing funding source.
  3. Select desired namespace from the 'Namespace' field.
  4. Select desired system code from the 'System Code' field.
  5. Select desired username from the 'Username' field.
  6. Click [Update Namespace/System Code For All Mappings].
  7. Click [OK].
  8. Validate the confirm dialog contains 'Namespace and System Code updated for all mappings on file.'.
  9. Click [OK].
  10. Validate the 'Funding Source/Guarantor Mapping' area contains list of guarantors.
  11. Select desired guarantors.
  12. Click [Submit].
Topics
• File Import • NX • Contracting Provider Service Authorization • Budget Tracking • Claims Processing • Funding Source
 

Avatar_MSO_2024_Monthly_Release_2024.00.00_Details.csv