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Avatar MSO 2024 Monthly Release 2024.02.00 Acceptance Tests

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Update 14 Summary | Details
Guardiant - metric processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Guardiant
  • Guardiant Application - Analytics
Scenario 1: Guardiant Metric Processing/Data - Validations (Avatar MSO)
Specific Setup:
  • Have a system configured for "Guardiant" reporting
  • Logged in user has access to the "Guardiant" form in Avatar and the "Guardiant" application
Steps
  1. Open form "Guardiant"
  2. Click [Test Daily Collection]
  3. Validate message "Test Succeeded" is displayed
  4. Click [Yes] to the warning message
  5. Validate message "Test Succeeded" is displayed
  6. Click [Test Metrics Collection]
  7. Validate message "Test Succeeded" is displayed
  8. Click [Yes] to the warning message
  9. Validate message "Test Succeeded" is displayed
  10. Log into "Guardiant"
  11. At the "Client Search", select the desired client account number
  12. Click "Analytics" from the menu on the right side panel
  13. Click the "Finance" tab at the top of the page
  14. Navigate to the "# of 835 Files Produced in MSO" graph
  15. Hover over the current date and a previous date on the graph
  16. Validate the values displayed, are as expected
  17. Navigate to the "# of 837 Files Produced in MSO" graph
  18. Hover over the current date and a previous date on the graph
  19. Validate the values displayed, are as expected
Topics
• 837 Professional
Update 21 Summary | Details
Avatar MSO 'Replacement Claim Assignment (CMS-1500)' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Replacement Claim Assignment (CMS-1500)
  • Retro Claim Adjudication
  • Claim Processing (CMS 1500)
Scenario 1: 'Replacement Claim Assignment (CMS-1500)' - Verification of Retro Claim Adjudication and Claim/Service Filing
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' may optionally be enabled
  • Avatar MSO Registry Setting 'Batch Naming Convention' may optionally be enabled/configured to value other than default
  • 'Default Retro Claim Adjudication Adjustment Code For 837 Professional Voids' / 'Default Retro Claim Adjudication Adjustment Code For 837 Institutional Voids' must be defined (via Avatar MSO 'Set System Defaults' form)
  • Client record with 'Closed' CMS-1500/Professional claim(s)/service(s) eligible for Replacement/Retro Claim Adjudication entry (optionally where original services filed to/existing in Avatar PM/Cal-PM parent system)
  • Crystal Reports or other SQL Reporting tool
Steps
  1. Open Avatar MSO 'Replacement Claim Assignment (CMS-1500)' form.
  2. Select 'Claim' or 'Service' in 'Replacement Options' field.
  3. Enter values for 'From Date' and 'Through Date' fields; enter/select value in 'Client ID' field (and any other Replacement Claim/Service selection criteria fields as desired).
  4. Select claim or services for Replacement Claim Assignment entry:
  5. Where 'Claim' is selected in 'Replacement Options' field, select claim for replacement in 'Claim Number' field
  6. Where 'Service' is selected in 'Replacement Options' field, click 'Select Services To Replace' button/select one or more services for Replacement Claim/Service Assignment and click 'OK' button
  7. Following Claim or Service selection for Replacement Claim Assignment, navigate to 'Service Detail' section of form.
  8. Update/enter service information for Replacement Claim Assignment service rows as desired; add or delete service Replacement Claim Assignment service rows as desired.
  9. When Replacement Claim Assignment Service Detail information/entries are complete, navigate to main/first section of form.
  10. Click 'File' button to file/save 'Replacement Claim Assignment (CMS-1500)' form/entry.
  11. On filing of 'Replacement Claim Assignment (CMS-1500)' form/entry - ensure that user is presented with confirmation dialog noting Claims Processing batch information for new claim/services created.
  12. Example: 'Batch Created: Replacement Claim Assignment 2345'
  13. New Claims Processing batch will be created for Replacement Claim Assignment claims if no open Replacement Claim Assignment batch exists for today's date/criteria
  14. If open Replacement Claim Assignment batch exists for today's date/criteria, Replacement Claim Assignment claims will be added to open/existing batch and new Claims Processing batch will not be created
  15. Replacement Claim Assignment batch names will regard Avatar MSO Registry Setting 'Batch Naming Convention'; if Registry Setting is enabled/configured to value other than default, Claims Processing batches created via 'Replacement Claim Assignment...' forms will include configured naming convention values
  16. Examples: 'Replacement Claim Assignment Medicaid 2024-06-24 Horizon House(1) 2346', 'Replacement Claim Assignment 2024-06-24 2397'
  17. Open Avatar MSO 'Retro Claim Adjudication' form.
  18. Note, Retro Claim Adjudication entries filed via the 'Replacement Claim Assignment...' forms may also be confirmed directly via Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications'
  19. Select 'Edit' in 'Add/Edit/Delete Claim Adjudication' field.
  20. In 'Claim' field, select original claim including replaced service(s) where 'Void' entry was filed via 'Replacement Claim Assignment (CMS-1500)' form.
  21. In 'Date Of Service/Procedure' field, select original/replaced service where 'Void' entry was filed via 'Replacement Claim Assignment (CMS-1500)' form.
  22. In 'Retro Claim Adjudication' form, ensure that 'Void' (full takeback) Retro Claim Adjudication information exists for selected original Claim/Service where 'Void' entry was filed via 'Replacement Claim Assignment (CMS-1500)' form, with information/values as follows:
  23. 'Updated Disbursement Amount' = 0
  24. 'Updated Approved Units' = 0
  25. 'Take Back Amount' = 'Original Disbursement Amount'
  26. 'Take Back Units' = 'Original Approved Units'
  27. 'Adjustment Code' contains code/value defined as system default Adjustment Code for Void
  28. Default Adjustment Code defined via Avatar MSO 'Set System Defaults' form, 'Default Retro Claim Adjudication Adjustment Code For 837 Professional Voids' / 'Default Retro Claim Adjudication Adjustment Code For 837 Institutional Voids' fields
  29. 'Comments' field for 'Void' Retro Claim Adjudication entry filed via 'Replacement Claim Assignment...' forms contains comment entry 'Retro rate adjustment created because of a void generated by the 'Replacement Claim Assignment' form'
  30. Open Crystal Reports or other SQL reporting tool.
  31. In Avatar MSO SQL table 'SYSTEM.batch_clm_void_replac', ensure that new rows are added via 'Replacement Claim Assignment (CMS-1500)' form/entry filing; this information links the Replacement Claim with Original Claim.
  32. In Avatar MSO SQL table 'SYSTEM.batch_clm_svc_void_replac', ensure that new rows are added via 'Replacement Claim Assignment (CMS-1500)' form/entry filing; this information links the Replacement Claim services with Original Claim services.
  33. Open Avatar MSO 'Claim Processing (CMS 1500)' form.
  34. Note, Claims/Services filed via the 'Replacement Claim Assignment...' forms may also be confirmed directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail
  35. Select Claims Processing batch created or updated via 'Replacement Claim Assignment (CMS-1500)' form/entry filing.
  36. Ensure that Replacement Claim is present in form pre-display; select/open replacement claim created via 'Replacement Claim Assignment (CMS-1500)' form/entry filing.
  37. Ensure that Claim Level information/values are present as entered/filed in the 'Replacement Claim Assignment (CMS-1500)' form, including 'Claim ID', 'Funding Source', 'Member Name Or ID', 'Provider', Diagnosis and all other Claim Level Information fields.
  38. Coordination Of Benefits/Other Healthcare Coverage Claim level information are filed with new Replacement claim entry where present in original claim if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled. This may be confirmed by clicking the 'Coordination Of Benefits' button in Claim Level Information section to review
  39. Navigate to 'Service Detail' section of form.
  40. Ensure that all service(s) entered/filed with Replacement Claim are present in form/populated as rows in 'Claim Service Detail History' Tabular Data Entry Grid.
  41. Select service row for edit/review in 'Claim Service Detail History' Tabular Data Entry Grid and click 'Edit Selected Item' button.
  42. Ensure that Service Level information/values are present as entered/filed in the 'Replacement Claim Assignment (CMS-1500)' form, including 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and all other Service Level Information fields.
  43. Coordination Of Benefits/Other Healthcare Coverage Service level information are filed with new Replacement service entry where present in original service if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled. This may be confirmed by clicking the 'Enter Third Party Adjudication Data' button in Service Level Information section to review
  44. Close Claims Processing batch created or updated via 'Replacement Claim Assignment (CMS-1500)' form/entry filing (via 'Close Batch' or 'Close Multiple Batches' form).
  45. In Avatar PM/Cal-PM parent system, confirm the following after closing of Claims Processing Batch for Replacement Claims/Services in MSO:
  46. Retro Claim Adjudication 'Void' entries from 'Replacement Claim Assignment...' form/entry are pushed/filed to Avatar PM/Cal-PM parent system on closing of Claims Processing Batch for Replacement Claims/Services in MSO
  47. Original services in 'Open' charge status will be deleted in Avatar PM/Cal-PM parent system on pushing of Retro Claim Adjudication 'Void' entries from 'Replacement Claim Assignment...' filing
  48. Original services in 'Closed' and 'Unbilled' charge status (not claimed) will have service deletion reversal code ('DELETE') filed in Avatar PM/Cal-PM parent system on pushing of Retro Claim Adjudication 'Void' entries from 'Replacement Claim Assignment...' filing
  49. Original services which have been included in 837 Electronic Billing outbound claim in Avatar PM/Cal-PM parent system (claimed) will remain in parent system as originally filed, and 'Electronic Re-Billing Service Assignment' entries will be created in Avatar PM/Cal-PM for original claims/services where enabled (with 'Replacement of Prior Claim' Claim Submission Reason Code)
  50. In Avatar Cal-PM parent systems where Avatar Cal-PM Registry Setting 'Support Additional Claim Follow-Up Functionality' is enabled:
  51. 'Claim Follow-Up' entries will be created for original Avatar Cal-PM claims/services on filing of 'Replacement' claim in Avatar MSO
  52. 'Electronic Re-Billing Service Assignment' entries will only be created in Avatar Cal-PM for original claims and services where/when 835 Remittance Advice has been received/posted for original Avatar Cal-PM claim
  53. Ensure that 'Approved' status Replacement Claim new services are filed to Avatar PM/Cal-PM parent system under same episode as original/voided services
  54. Replacement Claim new services may optionally not be filed to Avatar PM/Cal-PM following 'Close Batch' and may be inhibited/held in Avatar MSO until further action dependent upon 'Service Filing' rules defined in 'MSO to Parent System Integration Mapping' form in same manner as all other services
Scenario 2: 'Replacement Claim Assignment (CMS-1500)' - Form Verification
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Additional Claim Level Fields' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Additional Fields' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Contracting Provider Program' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Group Services' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Service Times' may optionally be enabled
  • Avatar MSO Registry Setting 'Display Duration' may optionally be enabled
  • Claim Adjudication Approve/Pend/Deny Rule 'Maximum Number Of Days Prior To 'Date Claims Received' Date Of Service Is Permitted For Replacement Claims' may optionally be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Avatar MSO CPT Codes may optionally be defined with 'Primary Code' / 'Add-On Code' / 'Interactive Complexity' CPT Code Category (via Avatar MSO 'CPT Code Definition' form)
  • Client record with 'Closed' CMS-1500/Professional claim(s)/service(s) eligible for Replacement/Retro Claim Adjudication entry
Steps
  1. Open Avatar MSO 'Replacement Claim Assignment (CMS-1500)' form (under 'Avatar MSO -> Claims Processing' menu path).
  2. Ensure that the following sections/fields are present in the 'Replacement Claim Assignment (CMS-1500)' form main/first form section:
  3. 'Replacement Options'
  4. Allows selection of 'Claim' or 'Service' type Replacement Claim/Service selection
  5. 'From Date' / 'Through Date'
  6. Where 'Claim' is selected in 'Replacement Options' field, date criteria will limit by 'Date Claim Received' for original claims; Required
  7. Where 'Service' is selected in 'Replacement Options' field, date criteria will limit by Service Date for original claims/services; Required
  8. Maximum time period/span of 365 days allowed for date criteria entry; future dates disallowed
  9. 'Client ID'
  10. Client ID for Replacement claim/service selection; Required
  11. 'Contracting Provider'
  12. Contracting Provider for Replacement claim/service selection filtering; Optional
  13. 'Contracting Provider Program'
  14. Contracting Provider Program for Replacement claim/service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
  15. 'Performing Provider'
  16. Performing Provider for Replacement claim/service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
  17. 'Batch Number'
  18. Original Batch ID for Replacement claim/service selection filtering; Optional
  19. 'Claim Number'
  20. Allows selection of original claim for Replacement claim/service entry
  21. Where 'Claim' is selected in 'Replacement Options' field, 'Claim Number' field selection is required and will trigger claim/service information population in form
  22. Where 'Service' is selected in 'Replacement Options' field, 'Claim Number' field selection is optional and will function as additional service selection filter/criteria field
  23. 'Procedure Code'
  24. CPT/Procedure Code for Replacement claim/service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional, enabled only where 'Service' is selected in 'Replacement Options' field
  25. 'Date Replacement Claim Received'
  26. Will be used as 'Date Claim Received' value for new claim/services filed via 'Replacement Claim Assignment (CMS-1500)' form, defaulted to current date; Required
  27. 'Select Services To Replace' Button
  28. Enabled only where 'Service' is selected in 'Replacement Options' field
  29. 'File' Button
  30. Select 'Claim' or 'Service' in 'Replacement Options' field.
  31. Enter values for 'From Date' and 'Through Date' fields.
  32. Enter/select value in 'Client ID' field.
  33. Enter/select values in 'Contracting Provider', 'Contracting Provider Program', 'Performing Provider' and/or 'Batch Number' Replacement claim/service selection criteria fields if desired (and/or 'Claim Number'/'Procedure Code' fields where 'Service' is selected in 'Replacement Options' field, if desired).
  34. Where 'Claim' is selected in 'Replacement Options' field...
  35. Ensure that 'Claim Number' field selections are limited to original Avatar MSO CMS-1500 (Professional) claims in 'Closed' status batches meeting Replacement claim selection criteria values (and where Replacement claim has not been previously filed)
  36. Ensure that 'Claim Number' field display includes original Batch ID, Claim Number, Contracting Provider, Total Charges and Unique ID values for all selections
  37. If no CMS-1500 (Professional) claims in 'Closed' status batches meeting Replacement claim selection criteria values, ensure that 'Claim Number' selection field is blank/shows no claims for selection
  38. Select claim for replacement in 'Claim Number' field - this will result in all services in selected claim being populated in 'Replacement Claim Assignment (CMS-1500)' form 'Service Detail' section
  39. Where 'Service' is selected in 'Replacement Options' field...
  40. Click 'Select Services To Replace' button; ensure that Replacement Claim 'Select Service(s) To Replace' selection dialog is presented
  41. Ensure that Replacement Claim Service Selection selections are limited to original Avatar MSO CMS-1500 (Professional) services in 'Closed' status batches meeting Replacement claim selection criteria values (and where Replacement claim/service has not been previously filed)
  42. If no CMS-1500 (Professional) services in 'Closed' status batches meeting Replacement claim selection criteria values, ensure that 'No Services Found' dialog/message is displayed in lieu of 'Select Service(s) To Replace' dialog
  43. Ensure that 'Select Service(s) To Replace' dialog display includes 'Client', 'Contracting Provider', 'Performing Provider' and 'Contracting Provider Program' values from Replacement claim selection criteria values
  44. Ensure that 'Select Service(s) To Replace' dialog display includes original Batch ID, Date of Service, Claim Number, Procedure Code, Charges, Duration, Units and Total Disbursement values for all available service selections
  45. For service(s) which are 'Primary Code' services including one or more Add-On and/or Interactive Complexity services, ensure that Service Code is denoted with an asterisk (*) in 'Select Services To Replace' dialog
  46. On inclusion/selection of 'Primary Code' service for Replacement Claim/Service Assignment, all related Add-On and/or Interactive Complexity will automatically be included/populated in 'Replacement Claim Assignment (CMS-1500)' form 'Service Detail' section
  47. Select one or more services for Replacement Claim/Service Assignment (limiting selected services to single original Claim Number) and click 'OK' button - this will result in all services in selected claim being populated in 'Replacement Claim Assignment (CMS-1500)' form 'Service Detail' section
  48. In case where services from more than one/single original Claim are selected for Replacement Claim/Service Assignment - on clicking 'OK' button, ensure that error dialog is presented noting 'Only one claim can be replaced at a time' and selections are disallowed.
  49. Ensure that attempting to change 'Claim ID' or selected services after Replacement Claim Assignment claim/service selection results in error dialog noting 'Previously populated rows in the Service Detail section must be manually deleted before new services can be selected' and claim/service change is disallowed.
  50. Following Claim or Service selection for Replacement Claim Assignment, navigate to 'Claim Processing (CMS 1500)' section of form.
  51. Ensure that the following sections/fields are present in the 'Replacement Claim Assignment (CMS-1500)' form 'Claim Processing (CMS 1500)' section:
  52. 'Claim ID'
  53. Claim ID for new/Replacement claim to be created; assigned by Avatar MSO
  54. 'Funding Source'
  55. 'Member Name Or ID'
  56. 'Provider'
  57. Diagnosis and Claim Level Information fields
  58. Includes same fields as 'Claim Processing (CMS 1500)' form
  59. Claim level information fields present in form subject to/configured via Avatar MSO Registry Settings
  60. Ensure that 'Funding Source', 'Member Name Or ID', 'Provider' and all Diagnosis and Claim Level Information fields in form are populated with values from original claim selected for Replacement Claim Assignment entry (where values present in original claim for all optional claim information fields).
  61. Where 'Service' is selected for 'Replacement Options', Claim Level Information will be populated from original claim for selected service(s)
  62. Coordination Of Benefits/Other Healthcare Coverage Claim level information will also be populated/filed with new Replacement claim entry where present in original claim if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled
  63. Ensure that all fields within 'Claim Processing (CMS 1500)' section of 'Replacement Claim Assignment (CMS-1500)' form are disabled/read-only (original claim level information may not be altered for CMS-1500/Professional Replacement claims).
  64. Following Claim or Service selection for Replacement Claim Assignment, navigate to 'Service Detail' section of form.
  65. Ensure that the following sections/fields are present in the 'Replacement Claim Assignment (CMS-1500)' form 'Service Detail' section:
  66. 'Claim Service Detail History' Tabular Data Entry Grid
  67. Including 'Add New Item'/'Edit Selected Item'/'Delete Selected Item' buttons
  68. 'Date of Service'
  69. 'Procedure Code'
  70. 'Total Charge'
  71. 'Service Units'
  72. 'Claim Status'/'Claim Status Reason'/'Explanation Of Coverage'/'Approved Units'/'Expected Disbursement'
  73. Populated via Avatar MSO Claim Processing/Adjudication functions as in 'Claim Processing (CMS 1500)' form
  74. Other Service Level Information fields
  75. Includes same fields as in 'Claim Processing (CMS 1500)' form 'Service Detail' section
  76. Includes 'Display Valid Authorizations' button
  77. Coordination Of Benefits/Other Healthcare Coverage Service level information will also be populated/filed with new Replacement service entry where present in original service if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled. This may be reviewed/updated by clicking the 'Enter Third Party Adjudication Data' button in Service Level Information section
  78. Service level information fields present in form subject to/configured via Avatar MSO Registry Settings
  79. Multiple service entry fields are disabled in 'Replacement Claim Assignment (CMS-1500)' form (in case where present due to Avatar MSO 'Enable Multiple Service Date Entry' Registry Setting)
  80. Where 'Claim' was selected in 'Replacement Options' field (and claim selected) - Ensure that all service(s) from selected Claim are present in form/populated as rows in 'Claim Service Detail History' Tabular Data Entry Grid following Claim selection for Replacement Claim Assignment.
  81. Where 'Service' was selected in 'Replacement Options' field (and services selected) - Ensure that selected service(s) are present in form/populated as rows in 'Claim Service Detail History' Tabular Data Entry Grid.
  82. Where 'Service' was selected in 'Replacement Options' field (and services selected) - Ensure that on inclusion/selection of 'Primary Code' service for Replacement Claim/Service Assignment, all related Add-On and/or Interactive Complexity are also included/populated as rows in 'Claim Service Detail History' Tabular Data Entry Grid.
  83. Select service row for edit/review in 'Claim Service Detail History' Tabular Data Entry Grid and click 'Edit Selected Item' button.
  84. Ensure that 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and all Service Level Information fields in form are populated with values from corresponding original service selected for Replacement Claim Assignment entry (where values present in original service for all optional service level information fields).
  85. Ensure that all fields within 'Service Detail' section of 'Replacement Claim Assignment (CMS-1500)' are enabled for update/entry; ensure that all 'Service Detail' section fields are subject to field requirements as in 'Claim Processing (CMS 1500)' form 'Service Detail' section.
  86. Service level information fields enabled/required in form subject to/configured via Avatar MSO Registry Settings
  87. Ensure that Replacement Claim Assignment service rows are subject to Approve/Pend/Deny adjudication rules as in 'Claim Processing (CMS 1500)' form/adjudication and that 'Claim Status'/'Claim Status Reason'/'Explanation Of Coverage'/'Approved Units'/'Expected Disbursement' field values are present in form accordingly.
  88. Replacement Claim Assignment service rows will be considered/adjudicated under the 'Maximum Number Of Days Prior To 'Date Claims Received' Date Of Service Is Permitted For Replacement Claims' Claim Adjudication Approve/Pend/Deny Rule if limit defined, as compared to 'Date Replacement Claim Received' value from main/first section of 'Replacement Claim Assignment (CMS-1500)' form
  89. Update/enter service information for selected Replacement Claim Assignment service row as desired; select additional rows and update/enter service information as desired.
  90. Add or delete Replacement Claim Assignment service rows as desired using 'Add New Item'/'Delete Selected Item' buttons; added services will be filed under same/current Replacement claim.
  91. For service(s) which are 'Primary Code' services - ensure that on service row deletion, user is presented with dialog noting 'Primary Codes cannot be deleted. Utilize the 'Void Claim Assignment' form to void this service. Deleting the service will not remove it from the replacement claim.'
  92. When Replacement Claim Assignment Service Detail information/entries are complete, navigate to main/first section of form.
  93. Click 'File' button to file/save 'Replacement Claim Assignment (CMS-1500)' form/entry; ensure user is presented with filing confirmation dialog noting 'Selected services will be voided. Continue?'.
  94. Filing/saving of Replacement Claim Assignment (CMS-1500)' form/entry will result in Retro Claim Adjudication 'Void' (full takeback) entries created for original claim/service(s), and new claim/service(s) created for subsequent Claim Processing adjudication.
  95. Click 'Yes' button to continue/file 'Replacement Claim Assignment (CMS-1500)' entry (or click 'No' button to cancel filing and return to form for further entry/edit).
  96. For service(s) which are 'Primary Code' services - ensure that on attempting to file 'Replacement Claim Assignment (CMS-1500)' following deletion of one or more 'Primary Code' service rows from claim, user is presented with dialog noting 'Primary Services may not be deleted' and filing is cancelled
  97. On filing of 'Replacement Claim Assignment (CMS-1500)' form/entry - ensure that user is presented with confirmation dialog noting Claims Processing batch information for new claim/services created (example: 'Batch Created: Replacement Claim Assignment 2345 (2345)'); click 'OK' button to close dialog/form.
Avatar MSO 'Replacement Claim Assignment (UB-04)' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Replacement Claim Assignment (UB-04)
  • Retro Claim Adjudication
Scenario 1: 'Replacement Claim Assignment (UB-04)' - Verification of Retro Claim Adjudication and Claim/Service Filing
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' may optionally be enabled
  • Avatar MSO Registry Setting 'Batch Naming Convention' may optionally be enabled/configured to value other than default
  • 'Default Retro Claim Adjudication Adjustment Code For 837 Professional Voids' / 'Default Retro Claim Adjudication Adjustment Code For 837 Institutional Voids' must be defined (via Avatar MSO 'Set System Defaults' form)
  • Client record with 'Closed' UB-04/Institutional claim(s)/service(s) eligible for Replacement/Retro Claim Adjudication entry (optionally where original services filed to/existing in Avatar PM/Cal-PM parent system)
  • Crystal Reports or other SQL Reporting tool
Steps
  1. Open Avatar MSO 'Replacement Claim Assignment (UB-04)' form.
  2. Select 'Claim' or 'Service' in 'Replacement Options' field.
  3. Enter values for 'From Date' and 'Through Date' fields; enter/select value in 'Client ID' field (and any other Replacement Claim/Service selection criteria fields as desired).
  4. Select claim or services for Replacement Claim Assignment entry:
  5. Where 'Claim' is selected in 'Replacement Options' field, select claim for replacement in 'Claim Number' field
  6. Where 'Service' is selected in 'Replacement Options' field, click 'Select Services To Replace' button/select one or more services for Replacement Claim/Service Assignment and click 'OK' button
  7. Following Claim or Service selection for Replacement Claim Assignment, navigate to 'Claim Processing (UB92)' section of form.
  8. Update/enter claim level information for Replacement Claim Assignment claim as desired.
  9. Following Claim or Service selection for Replacement Claim Assignment, navigate to 'Service Detail' section of form.
  10. Update/enter service information for Replacement Claim Assignment service rows as desired; add or delete service Replacement Claim Assignment service rows as desired.
  11. When Replacement Claim Assignment Service Detail information/entries are complete, navigate to main/first section of form.
  12. Click 'File' button to file/save 'Replacement Claim Assignment (UB-04)' form/entry.
  13. On filing of 'Replacement Claim Assignment (UB-04)' form/entry - ensure that user is presented with confirmation dialog noting Claims Processing batch information for new claim/services created.
  14. Example: 'Batch Created: Replacement Claim Assignment 2345'
  15. New Claims Processing batch will be created for Replacement Claim Assignment claims if no open Replacement Claim Assignment batch exists for today's date/criteria
  16. If open Replacement Claim Assignment batch exists for today's date/criteria, Replacement Claim Assignment claims will be added to open/existing batch and new Claims Processing batch will not be created
  17. Replacement Claim Assignment batch names will regard Avatar MSO Registry Setting 'Batch Naming Convention'; if Registry Setting is enabled/configured to value other than default, Claims Processing batches created via 'Replacement Claim Assignment...' forms will include configured naming convention values
  18. Examples: 'Replacement Claim Assignment Medicaid 2024-06-24 Horizon House(1) 2346', 'Replacement Claim Assignment 2024-06-24 2397'
  19. Open Avatar MSO 'Retro Claim Adjudication' form.
  20. Note, Retro Claim Adjudication entries filed via the 'Replacement Claim Assignment...' forms may also be confirmed directly via Avatar MSO SQL table 'SYSTEM.retro_claim_adjudications'
  21. Select 'Edit' in 'Add/Edit/Delete Claim Adjudication' field.
  22. In 'Claim' field, select original claim including replaced service(s) where 'Void' entry was filed via 'Replacement Claim Assignment (UB-04)' form.
  23. In 'Date Of Service/Procedure' field, select original/replaced service where 'Void' entry was filed via 'Replacement Claim Assignment (UB-04)' form.
  24. In 'Retro Claim Adjudication' form, ensure that 'Void' (full takeback) Retro Claim Adjudication information exists for selected original Claim/Service where 'Void' entry was filed via 'Replacement Claim Assignment (UB-04)' form, with information/values as follows:
  25. 'Updated Disbursement Amount' = 0
  26. 'Updated Approved Units' = 0
  27. 'Take Back Amount' = 'Original Disbursement Amount'
  28. 'Take Back Units' = 'Original Approved Units'
  29. 'Adjustment Code' contains code/value defined as system default Adjustment Code for Void
  30. Default Adjustment Code defined via Avatar MSO 'Set System Defaults' form, 'Default Retro Claim Adjudication Adjustment Code For 837 Professional Voids' / 'Default Retro Claim Adjudication Adjustment Code For 837 Institutional Voids' fields
  31. 'Comments' field for 'Void' Retro Claim Adjudication entry filed via 'Replacement Claim Assignment...' forms contains comment entry 'Retro rate adjustment created because of a void generated by the 'Replacement Claim Assignment' form'
  32. Open Crystal Reports or other SQL reporting tool.
  33. In Avatar MSO SQL table 'SYSTEM.batch_clm_void_replac', ensure that new rows are added via 'Replacement Claim Assignment (UB-04)' form/entry filing; this information links the Replacement Claim with Original Claim.
  34. In Avatar MSO SQL table 'SYSTEM.batch_clm_svc_void_replac', ensure that new rows are added via 'Replacement Claim Assignment (UB-04)' form/entry filing; this information links the Replacement Claim services with Original Claim services.
  35. Open Avatar MSO 'Claim Processing (UB-04)' form.
  36. Note, Claims/Services filed via the 'Replacement Claim Assignment...' forms may also be confirmed directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail
  37. Select Claims Processing batch created or updated via 'Replacement Claim Assignment (UB-04)' form/entry filing.
  38. Ensure that Replacement Claim is present in form pre-display; select/open replacement claim created via 'Replacement Claim Assignment (UB-04)' form/entry filing.
  39. Ensure that Claim Level information/values are present as entered/filed in the 'Replacement Claim Assignment (UB-04)' form, including 'Claim ID', 'Funding Source', 'Member Name Or ID', 'Provider', Diagnosis and all other Claim Level Information fields.
  40. Coordination Of Benefits/Other Healthcare Coverage Claim level information are filed with new Replacement claim entry where present in original claim if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled. This may be confirmed by clicking the 'Coordination Of Benefits' button in Claim Level Information section to review
  41. Navigate to 'Service Detail' section of form.
  42. Ensure that all service(s) entered/filed with Replacement Claim are present in form/populated as rows in 'Claim Service Detail History' Tabular Data Entry Grid.
  43. Select service row for edit/review in 'Claim Service Detail History' Tabular Data Entry Grid and click 'Edit Selected Item' button.
  44. Ensure that Service Level information/values are present as entered/filed in the 'Replacement Claim Assignment (UB-04)' form, including 'Date of Service', 'Revenue Code' (and/or 'CPT Code' if applicable), 'Total Charge', 'Service Units' and all other Service Level Information fields.
  45. Coordination Of Benefits/Other Healthcare Coverage Service level information are filed with new Replacement service entry where present in original service if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled. This may be confirmed by clicking the 'Enter Third Party Adjudication Data' button in Service Level Information section to review
  46. Close Claims Processing batch created or updated via 'Replacement Claim Assignment (UB-04)' form/entry filing (via 'Close Batch' or 'Close Multiple Batches' form).
  47. In Avatar PM/Cal-PM parent system, confirm the following after closing of Claims Processing Batch for Replacement Claims/Services in MSO:
  48. Retro Claim Adjudication 'Void' entries from 'Replacement Claim Assignment...' form/entry are pushed/filed to Avatar PM/Cal-PM parent system on closing of Claims Processing Batch for Replacement Claims/Services in MSO
  49. Original services in 'Open' charge status will be deleted in Avatar PM/Cal-PM parent system on pushing of Retro Claim Adjudication 'Void' entries from 'Replacement Claim Assignment...' filing
  50. Original services in 'Closed' and 'Unbilled' charge status (not claimed) will have service deletion reversal code ('DELETE') filed in Avatar PM/Cal-PM parent system on pushing of Retro Claim Adjudication 'Void' entries from 'Replacement Claim Assignment...' filing
  51. Original services which have been included in 837 Electronic Billing outbound claim in Avatar PM/Cal-PM parent system (claimed) will remain in parent system as originally filed, and 'Electronic Re-Billing Service Assignment' entries will be created in Avatar PM/Cal-PM for original claims/services where enabled (with 'Replacement of Prior Claim' Claim Submission Reason Code)
  52. In Avatar Cal-PM parent systems where Avatar Cal-PM Registry Setting 'Support Additional Claim Follow-Up Functionality' is enabled:
  53. 'Claim Follow-Up' entries will be created for original Avatar Cal-PM claims/services on filing of 'Replacement' claim in Avatar MSO
  54. 'Electronic Re-Billing Service Assignment' entries will only be created in Avatar Cal-PM for original claims and services where/when 835 Remittance Advice has been received/posted for original Avatar Cal-PM claim
  55. Ensure that 'Approved' status Replacement Claim new services are filed to Avatar PM/Cal-PM parent system under same episode as original/voided services
  56. Replacement Claim new services may optionally not be filed to Avatar PM/Cal-PM following 'Close Batch' and may be inhibited/held in Avatar MSO until further action dependent upon 'Service Filing' rules defined in 'MSO to Parent System Integration Mapping' form in same manner as all other services
Scenario 2: 'Replacement Claim Assignment (UB-04)' - Form Verification
Specific Setup:
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Additional Claim Level Fields' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Additional Fields' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Contracting Provider Program' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Group Services' may optionally be enabled
  • Avatar MSO Registry Setting 'Enable Service Times' may optionally be enabled
  • Avatar MSO Registry Setting 'Display Duration' may optionally be enabled
  • Avatar MSO Registry Setting 'Allow All Procedure Code Types for UB Claim' may optionally be enabled
  • Claim Adjudication Approve/Pend/Deny Rule 'Maximum Number Of Days Prior To 'Date Claims Received' Date Of Service Is Permitted For Replacement Claims' may optionally be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Client record with 'Closed' UB-04/Institutional claim(s)/service(s) eligible for Replacement/Retro Claim Adjudication entry
Steps
  1. Open Avatar MSO 'Replacement Claim Assignment (UB-04)' form (under 'Avatar MSO -> Claims Processing' menu path).
  2. Ensure that the following sections/fields are present in the 'Replacement Claim Assignment (UB-04)' form main/first form section:
  3. 'Replacement Options'
  4. Allows selection of 'Claim' or 'Service' type Replacement Claim/Service selection
  5. 'From Date' / 'Through Date'
  6. Where 'Claim' is selected in 'Replacement Options' field, date criteria will limit by 'Date Claim Received' for original claims; Required
  7. Where 'Service' is selected in 'Replacement Options' field, date criteria will limit by Service Date for original claims/services; Required
  8. Maximum time period/span of 365 days allowed for date criteria entry; future dates disallowed
  9. 'Client ID'
  10. Client ID for Replacement claim/service selection; Required
  11. 'Contracting Provider'
  12. Contracting Provider for Replacement claim/service selection filtering; Optional
  13. 'Contracting Provider Program'
  14. Contracting Provider Program for Replacement claim/service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
  15. 'Performing Provider'
  16. Performing Provider for Replacement claim/service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
  17. 'Batch Number'
  18. Original Batch ID for Replacement claim/service selection filtering; Optional
  19. 'Claim Number'
  20. Allows selection of original claim for Replacement claim/service entry
  21. Where 'Claim' is selected in 'Replacement Options' field, 'Claim Number' field selection is required and will trigger claim/service information population in form
  22. Where 'Service' is selected in 'Replacement Options' field, 'Claim Number' field selection is optional and will function as additional service selection filter/criteria field
  23. 'Procedure Code'
  24. Revenue/Procedure Code for Replacement claim/service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional, enabled only where 'Service' is selected in 'Replacement Options' field
  25. 'Date Replacement Claim Received'
  26. Will be used as 'Date Claim Received' value for new claim/services filed via 'Replacement Claim Assignment (UB-04)' form, defaulted to current date; Required
  27. 'Select Services To Replace' Button
  28. Enabled only where 'Service' is selected in 'Replacement Options' field
  29. 'File' Button
  30. Select 'Claim' or 'Service' in 'Replacement Options' field.
  31. Enter values for 'From Date' and 'Through Date' fields.
  32. Enter/select value in 'Client ID' field.
  33. Enter/select values in 'Contracting Provider', 'Contracting Provider Program', 'Performing Provider' and/or 'Batch Number' Replacement claim/service selection criteria fields if desired (and/or 'Claim Number'/'Procedure Code' fields where 'Service' is selected in 'Replacement Options' field, if desired).
  34. Where 'Claim' is selected in 'Replacement Options' field...
  35. Ensure that 'Claim Number' field selections are limited to original Avatar MSO UB-04 (Institutional) claims in 'Closed' status batches meeting Replacement claim selection criteria values (and where Replacement claim has not been previously filed)
  36. Ensure that 'Claim Number' field display includes original Batch ID, Claim Number, Contracting Provider, Total Charges and Unique ID values for all selections
  37. If no UB-04 (Institutional) claims in 'Closed' status batches meeting Replacement claim selection criteria values, ensure that 'Claim Number' selection field is blank/shows no claims for selection
  38. Select claim for replacement in 'Claim Number' field - this will result in all services in selected claim being populated in 'Replacement Claim Assignment (UB-04)' form 'Service Detail' section
  39. Where 'Service' is selected in 'Replacement Options' field...
  40. Click 'Select Services To Replace' button; ensure that Replacement Claim 'Select Service(s) To Replace' selection dialog is presented
  41. Ensure that Replacement Claim Service Selection selections are limited to original Avatar MSO UB-04 (Institutional) services in 'Closed' status batches meeting Replacement claim selection criteria values (and where Replacement claim/service has not been previously filed)
  42. If no UB-04 (Institutional) services in 'Closed' status batches meeting Replacement claim selection criteria values, ensure that 'No Services Found' dialog/message is displayed in lieu of 'Select Service(s) To Replace' dialog
  43. Ensure that 'Select Service(s) To Replace' dialog display includes 'Client', 'Contracting Provider', 'Performing Provider' and 'Contracting Provider Program' values from Replacement claim selection criteria values
  44. Ensure that 'Select Service(s) To Replace' dialog display includes original Batch ID, Date of Service, Claim Number, Procedure Code, Charges, Duration, Units and Total Disbursement values for all available service selections
  45. Select one or more services for Replacement Claim/Service Assignment (limiting selected services to single original Claim Number) and click 'OK' button - this will result in all services in selected claim being populated in 'Replacement Claim Assignment (UB-04)' form 'Service Detail' section
  46. In case where services from more than one/single original Claim are selected for Replacement Claim/Service Assignment - on clicking 'OK' button, ensure that error dialog is presented noting 'Only one claim can be replaced at a time' and selections are disallowed.
  47. Ensure that attempting to change 'Claim ID' or selected services after Replacement Claim Assignment claim/service selection results in error dialog noting 'Previously populated rows in the Service Detail section must be manually deleted before new services can be selected' and claim/service change is disallowed.
  48. Following Claim or Service selection for Replacement Claim Assignment, navigate to 'Claim Processing (UB92)' section of form.
  49. Ensure that the following sections/fields are present in the 'Replacement Claim Assignment (UB-04)' form 'Claim Processing (UB92)' section:
  50. 'Claim ID'
  51. Claim ID for new/Replacement claim to be created; assigned by Avatar MSO
  52. 'Funding Source'
  53. 'Member Name Or ID'
  54. 'Provider'
  55. Diagnosis and Claim Level Information fields
  56. Includes same fields as 'Claim Processing (UB-04)' form
  57. Claim level information fields present in form subject to/configured via Avatar MSO Registry Settings
  58. Ensure that 'Funding Source', 'Member Name Or ID', 'Provider' and all Diagnosis and Claim Level Information fields in form are populated with values from original claim selected for Replacement Claim Assignment entry (where values present in original claim for all optional claim information fields).
  59. Where 'Service' is selected for 'Replacement Options', Claim Level Information will be populated from original claim for selected service(s)
  60. Coordination Of Benefits/Other Healthcare Coverage Claim level information will also be populated/filed with new Replacement claim entry where present in original claim if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled. This may be confirmed by clicking the 'Coordination Of Benefits' button in Claim Level Information section to review
  61. Ensure that all fields within 'Claim Processing (UB92)' section of 'Replacement Claim Assignment (UB-04)' form are enabled and may be edited/updated (original claim level information may be altered for UB-04/Institutional Replacement claims).
  62. Following Claim or Service selection for Replacement Claim Assignment, navigate to 'Service Detail' section of form.
  63. Ensure that the following sections/fields are present in the 'Replacement Claim Assignment (UB-04)' form 'Service Detail' section:
  64. 'Claim Service Detail History' Tabular Data Entry Grid
  65. Including 'Add New Item'/'Edit Selected Item'/'Delete Selected Item' buttons
  66. 'Date of Service'
  67. 'Revenue Code'
  68. 'Total Charge'
  69. 'Service Units'
  70. 'Claim Status'/'Claim Status Reason'/'Explanation Of Coverage'/'Approved Units'/'Expected Disbursement'
  71. Populated via Avatar MSO Claim Processing/Adjudication functions as in 'Claim Processing (UB-04)' form
  72. Other Service Level Information fields
  73. Includes same fields as in 'Claim Processing (UB-04)' form 'Service Detail' section
  74. Includes 'Display Valid Authorizations' button
  75. Coordination Of Benefits/Other Healthcare Coverage Service level information will also be populated/filed with new Replacement service entry where present in original service if Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' is enabled. This may be reviewed/updated by clicking the 'Enter Third Party Adjudication Data' button in Service Level Information section
  76. Service level information fields present in form subject to/configured via Avatar MSO Registry Settings
  77. Multiple service entry fields are disabled in 'Replacement Claim Assignment (UB-04)' form (in case where present due to Avatar MSO 'Enable Multiple Service Date Entry' Registry Setting)
  78. Where 'Claim' was selected in 'Replacement Options' field (and claim selected) - Ensure that all service(s) from selected Claim are present in form/populated as rows in 'Claim Service Detail History' Tabular Data Entry Grid following Claim selection for Replacement Claim Assignment.
  79. Where 'Service' was selected in 'Replacement Options' field (and services selected) - Ensure that selected service(s) are present in form/populated as rows in 'Claim Service Detail History' Tabular Data Entry Grid.
  80. Select service row for edit/review in 'Claim Service Detail History' Tabular Data Entry Grid and click 'Edit Selected Item' button.
  81. Ensure that 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and all Service Level Information fields in form are populated with values from corresponding original service selected for Replacement Claim Assignment entry (where values present in original service for all optional service level information fields).
  82. Ensure that all fields within 'Service Detail' section of 'Replacement Claim Assignment (UB-04)' are enabled for update/entry; ensure that all 'Service Detail' section fields are subject to field requirements as in 'Claim Processing (UB-04)' form 'Service Detail' section.
  83. Service level information fields enabled/required in form subject to/configured via Avatar MSO Registry Settings
  84. Ensure that Replacement Claim Assignment service rows are subject to Approve/Pend/Deny adjudication rules as in 'Claim Processing (UB-04)' form/adjudication and that 'Claim Status'/'Claim Status Reason'/'Explanation Of Coverage'/'Approved Units'/'Expected Disbursement' field values are present in form accordingly.
  85. Replacement Claim Assignment service rows will be considered/adjudicated under the 'Maximum Number Of Days Prior To 'Date Claims Received' Date Of Service Is Permitted For Replacement Claims' Claim Adjudication Approve/Pend/Deny Rule if limit defined, as compared to 'Date Replacement Claim Received' value from main/first section of 'Replacement Claim Assignment (UB-04)' form
  86. Update/enter service information for selected Replacement Claim Assignment service row as desired; select additional rows and update/enter service information as desired.
  87. Add or delete Replacement Claim Assignment service rows as desired using 'Add New Item'/'Delete Selected Item' buttons; added services will be filed under same/current Replacement claim.
  88. When Replacement Claim Assignment Service Detail information/entries are complete, navigate to main/first section of form.
  89. Click 'File' button to file/save 'Replacement Claim Assignment (UB-04)' form/entry; ensure user is presented with filing confirmation dialog noting 'Selected services will be voided. Continue?'.
  90. Filing/saving of Replacement Claim Assignment (UB-04)' form/entry will result in Retro Claim Adjudication 'Void' (full takeback) entries created for original claim/service(s), and new claim/service(s) created for subsequent Claim Processing adjudication.
  91. Click 'Yes' button to continue/file 'Replacement Claim Assignment (UB-04)' entry (or click 'No' button to cancel filing and return to form for further entry/edit).
  92. On filing of 'Replacement Claim Assignment (UB-04)' form/entry - ensure that user is presented with confirmation dialog noting Claims Processing batch information for new claim/services created (example: 'Batch Created: Replacement Claim Assignment 2345 (2345)'); click 'OK' button to close dialog/form.
Avatar MSO 'Provider EOB Report'
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Provider EOB Report
  • Provider EOB Report - Report Display
Scenario 1: 'Provider EOB Report' - Form and Report Verification
Specific Setup:
  • One or more EOB(s) existing in system for display
Steps
  1. Open Avatar MSO 'Provider EOB Report' form (under 'Avatar MSO / MSO Reporting / Provider Management Reports' menu).
  2. Ensure 'Contracting Provider' EOB criteria field is required; enter/select Contracting Provider value.
  3. In case where Avatar ProviderConnect NX and sub-system codes are used, 'Contracting Provider' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code
  4. Ensure 'EOB' dropdown selection field populated with existing EOBs for selected Contracting Provider (including EOB Number, Date, Provider and Amount values in display).
  5. Select EOB for Provider EOB Report display.
  6. Click 'Launch EOB Report' button to view Provider EOB Report.
  7. In Provider EOB Report display, ensure that EOB/Service Remittance Advice information is displayed, including the following information where applicable:
  8. EOB Number
  9. EOB Amount
  10. EOB Date
  11. Check Number
  12. Check Amount
  13. Check Date
  14. Provider (including Provider Address information)
  15. Client Name / Client ID / Client DOB / Client Gender
  16. Date Claim Received
  17. Service Remittance Information (including Batch Svc Ref #, Claim #, Auth #, Date of Service, CPT Code, Status, Claimed Amount, Allowed Amount, Denied/Adjusted Amount, Member Co-Pay and Amount Paid information)
  18. In case where claim/service(s) are designated as 'Replacement' claim (filed via 837 Professional/Institutional inbound file processing and/or 'Replacement Claim Assignment...' forms) - Ensure that 'Claim #' value/display includes '(R)' to denote 'Replacement' claim
  19. In Provider EOB Report display for EOB including Adjustment/Retro Claim Adjudication entries, ensure that Adjustment/Retro Claim Adjudication information is displayed, including the following information where applicable:
  20. Current Claims
  21. Adjustment Total
  22. Client Name
  23. Adjustment Information (including Batch ID, Svc Ref, Date of Service, Procedure Code, Client ID, Status, Billed Amount, Paid Amount, Adjustment Date, Adjustment Amount, Adjustment Reason)
Avatar MSO 'Void Claim Assignment' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Void Claim Assignment
  • Retro Claim Adjudication
Scenario 1: 'Void Claim Assignment' - Form Verification
Specific Setup:
  • Client with claim(s)/services eligible for Retro Claim Adjudication entry in Avatar MSO (where no previous 'Void' Retro Claim Adjudication entry has been filed)
Steps
  1. Open Avatar MSO 'Void Claim Assignment' form (under 'Avatar MSO / Claims Processing' menu).
  2. Ensure that the following fields are present in 'Void Claim Assignment' form:
  3. 'From Date Of Service'
  4. Begin date of service to include for Void service selection; Required
  5. 'Through Date Of Service'
  6. Begin date of service to include for Void service selection; Required
  7. 'Client ID'
  8. Client ID for Void service selection; Required
  9. 'Contracting Provider'
  10. Contracting Provider for Void service selection filtering; Optional
  11. 'Contracting Provider Program'
  12. Contracting Provider Program for Void service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
  13. 'Performing Provider'
  14. Performing Provider for Void service selection filtering (available selections populated based on 'Contracting Provider' selection); Optional
  15. 'Select Services To Void' button
  16. 'File' button
  17. Enter value for 'From Date Of Service' and 'Through Date of Service' criteria fields.
  18. Ensure that if date span for 'From Date Of Service'/'Through Date of Service' is greater than 365 days, user is presented with an error dialog noting 'Selected Time Period cannot exceed a 365 day period' and the criteria entry is disallowed.
  19. Enter/select value for 'Client ID' criteria field.
  20. Enter/select value for 'Contracting Provider' criteria field if desired.
  21. In case where Avatar ProviderConnect NX and sub-system codes are used, 'Contracting Provider' lookup/selection/entry field allows selection of only Contracting Provider(s) applicable to/allowed for current sub-system code
  22. Select value for 'Contracting Provider Program' criteria field if desired.
  23. Select value for 'Performing Provider' criteria field if desired.
  24. Click 'Select Services To Void' button to display Void service selection dialog for service selection criteria entered.
  25. Ensure that 'Select Service(s) To Void' service selection dialog displays all service(s) in 'Closed' status Avatar MSO Claim Processing batch(es) for the selected client/service dates (and 'Contracting Provider'/'Contracting Provider Program'/'Performing Provider' if specified) where no previous 'Void' Retro Claim Adjudication entry has been filed for service.
  26. If no eligible services are found for selected client/service dates (and 'Contracting Provider'/'Contracting Provider Program'/'Performing Provider' if specified), ensure that user is presented with error dialog noting 'No Services Found' on clicking 'Select Services To Void' button.
  27. In the 'Select Service(s) To Void' dialog, ensure that all service(s) meeting service selection criteria are displayed for selection with the following information for each service:
  28. 'Client'
  29. 'Contracting Provider'
  30. 'Contacting Provider Program'
  31. 'Performing Provider'
  32. 'Batch'
  33. 'Date Of Service'
  34. 'Claim #'
  35. 'Procedure Code'
  36. 'Charges'
  37. 'Total Disbursement'
  38. Select one or more service(s) for 'Void' Retro Claim Adjudication entry (using checkbox selection field for each desired service).
  39. Click 'OK' button in the 'Select Service(s) To Void' to complete Void service selection.
  40. Click 'File' button in 'Void Claim Assignment' form to file 'Void' (full takeback) Retro Claim Adjudication entry for each/all selected service(s).
  41. Ensure user is presented with a 'Void Services' confirmation dialog noting 'Selected services will be voided. Continue?'; Click 'Yes' button to proceed with Void Claim Assignment service filing.
  42. On Void Claim Assignment filing, ensure user is presented with a confirmation dialog noting 'Filed'; click 'OK' button to close confirmation dialog.
  43. Re-enter/re-select values for 'From Date Of Service'/'Through Date of Service' and 'Client ID' Void service selection criteria fields (along with 'Contracting Provider'/'Contracting Provider Program'/'Performing Provider' if desired); Click 'Select Services To Void' button for Void service selection dialog display.
  44. Ensure that 'Select Service(s) To Void' service selection dialog excludes any service(s) where previous 'Void' Retro Claim Adjudication entry has been filed for service.
Avatar MSO to Parent System Service Filing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • MSO to Parent System Integration Mapping
Scenario 1: 'Close Batch' - Avatar MSO to PM/Cal-PM Parent System Service Filing, Verification of Service Filing For Previously Errored/Inhibited Services
Specific Setup:
  • 'File Services On Closing Of Batch Or Creation Of EOB' must be set to 'Yes' (via 'MSO to Parent System Integration Mapping' form)
  • Service Filing Inhibit Rule for 'Check Number For EOB' and/or 'EOB Creation' may optionally be defined for Avatar MSO Contracting Provider (via 'MSO to Parent System Integration Mapping' form)
  • Client record with service(s) originating in Avatar MSO eligible for service filing to Avatar PM/Cal-PM
Steps
  1. Open Avatar MSO 'Close Batch' or 'Close Multiple Batches' form.
  2. Note - Acceptance Testing may also be confirmed via Avatar MSO 'Claim Processing Automation' functionality for automatic posting/closing 837 file batches
  3. Select Claims Processing batch(es) to be closed.
  4. Set 'Close Batch' field to 'Yes' and submit form to close batch(es).
  5. For clients with 'Approved' status services ineligible for service filing to Avatar PM/Cal-PM due to one or more reasons (Example: where 'Service Filing Inhibit Rule' is defined for Contracting Provider), ensure that services are not filed/not present in Avatar PM/Cal-PM following 'Close Batch' action, pending correction of service push issue (example: EOB Creation and/or 'Check/EFT Number' entry for inclusive EOB).
  6. Service Filing Inhibition may be confirmed by service(s) not being included in Avatar PM/Cal-PM 'Client Ledger' display
  7. Service Filing Inhibition may also be confirmed via Avatar MSO SQL table 'SYSTEM.mso_to_pm_service_failed', with a row present for Claims Processing Batch ID/Service ID and applicable error messages (Examples: 'Service will be held from filing into PM until it is placed on an EOB' or 'Service will be held from filing into PM due to lack of a check number')
  8. On correction of service push error conditions and/or inclusion of service(s) in Avatar MSO EOB and/or 'Check/EFT Number' entry for inclusive EOB, ensure that eligible service(s) are successfully filed to Avatar PM/Cal-PM.
  9. Service Filing may be confirmed by service(s) being included in Avatar PM/Cal-PM 'Client Ledger' display
  10. Service Filing may also be confirmed via Avatar MSO SQL table 'SYSTEM.mso_to_pm_service_failed', with rows deleted for Claims Processing Batch ID/Service IDs previously filed due to Service Filing Inhibition
Pended claims/services in Avatar MSO 'Close Batch' form
Scenario 1: 'Close Batch' - Verification of New Batch Creation for 'Pending' Claims/Services
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
  • Avatar MSO Registry Setting 'Eligibility Check Warning' must be enabled
  • Avatar MSO Claims Processing batch(es) in 'Open' status with 'Pending' status claims/services, where 'Pending' claim/service status is due to failing Avatar PM/Cal-PM eligibility check service adjudication condition
Steps
  1. Open 'Close Batch' form.
  2. Set 'Close Batch' field to 'Yes', and file form. (Note - 'Close Batch' filing may also be confirmed via 'Claims Processing Automation' functionality for inbound 837 claims/services)
  3. Ensure 'Close Batch' form filing/processing is completed and form is closed on completion (without presence of 'This client is not eligible for this service. Avatar Financial Eligibility check failed' pop-up dialog presented for any 'Pending' status services failing Avatar PM/Cal-PM eligibility check service adjudication condition).
  4. For 'Pending' status claims/services in batch, ensure that new Claims Processing batch is automatically created by system on use of 'Close Batch' function.
  5. Ensure that new Claims Processing batch automatically created by system on use of 'Close Batch' function references the original batch name/number. (Example: 'Pended Service Batch 2301 - was 'HIPAA837P Claim Processing Batch 2300').
Avatar MSO to Avatar PM/Cal-PM Service Filing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • MSO to Parent System Integration Mapping
  • CPT Code Definition (MSO)
Scenario 1: 'Close Batch' - Avatar MSO to PM/Cal-PM Parent System Service Filing, Verification of Primary/Add-On/Interactive Complexity CPT Codes
Specific Setup:
  • Avatar MSO CPT Codes defined with 'Primary Code' / 'Add-On Code' / 'Interactive Complexity' CPT Code Category (via Avatar MSO 'CPT Code Definition' form)
  • One or more Avatar MSO originating claims containing 'Approved' status Primary and Add-On/Interactive Complexity service(s) eligible for filing to Avatar Cal-PM on Batch Closing
  • Crystal Reports or other SQL reporting tool
Steps
  1. In Avatar MSO, create one or more claims containing both 'Approved' status Primary and one or more Add-On/Interactive Complexity service(s) via inbound 837 Health Care Claim Professional posting/filing and/or manual entry (i.e. 'Fast Service Entry' form).
  2. Open Avatar MSO 'Close Batch' form.
  3. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM/Cal-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
  4. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status Primary and Add-On/Interactive Complexity service(s) in same/single claim eligible for filing to parent Avatar PM/Cal-PM system.
  5. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
  6. Click 'Submit' button to close batch/file services to parent Avatar PM/Cal-PM system.
  7. Open 'Client Ledger' form in parent Avatar PM/Cal-PM system.
  8. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
  9. Select 'Claim/Episode/All Episodes' value.
  10. Select 'Ledger Type' value.
  11. Click 'Process' button.
  12. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar PM/Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
  13. Close 'Client Ledger' form.
  14. Open Crystal Reports or other SQL reporting tool.
  15. In Avatar PM/Cal-PM parent system SQL table 'SYSTEM.billing_tx_history' - for new services/rows added via Avatar MSO Add-On/Interactive Complexity services, ensure that 'join_to_tx_hist_for_addon' field value contains related Primary Service ID ('JOIN_TO_TX_HISTORY' value) for all Add-On/Interactive Complexity services.
Topics
• Retro Claim Adjudication • Claims Processing • Replacement Claim Assignment • Reports • MSO To Parent System Integration Mapping • Close Batch • CPT Code Definition • 837 Professional
Update 22 Summary | Details
MSO - Members by Authorized Procedure Code
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • MembersByAuthorizedProcedureCode - Form
Scenario 1: Members by Authorized Procedure Code report
Specific Setup:
  • 'Client A':
  • A new client is created, or an existing one is identified and admitted to any Inpatient/ Outpatient program.
  • Has active diagnosis and financial eligibility records.
  • 'Funding Source 1':
  • An active funding source is created or identified.
  • 'Provider 1':
  • An active contracting provider is created or identified.
  • 'Provider 2':
  • An active contracting provider is created or identified.
  • Service Authorization(s):
  • For 'Client A' there are active service authorization records with valid begin and end dates, for 'Provider 1' and 'Provider 2'.
Steps
  1. Open 'Members By Authorized Procedure Code'.
  2. Verify that the form has the below field(s):
  3. Individual or All Providers:
  4. Is required and enabled.
  5. Provider:
  6. Verify this field is required or not based on the selected value in 'Individual or All Providers'.
  7. When 'Individual' is selected in 'Individual or All Providers' then it is required and enabled.
  8. When 'All' is selected in 'Individual or All Providers' then it is not required and disabled.
  9. Date,
  10. Is required and enabled.
  11. Leave all the required fields empty and click [Process].
  12. Verify an error message displays for the missing mandatory fields.
  13. Click [OK].
  14. Select 'Individual' in the 'Individual or All Providers' field.
  15. Enter any desired date in 'Date', that falls in the provider's authorization begin and end date range from the setup.
  16. Leave the field 'Provider' empty and click [Process].
  17. Verify an error message displayed for the missing mandatory field.
  18. Click [OK].
  19. Select 'Provider 1'.
  20. Click [Process].
  21. Verify that the report generated with the active service authorizations of 'Provider 1'.
  22. Click [Close Report].
  23. Click [Yes].
  24. Select 'All' in the 'Individual or All Providers' field.
  25. Enter any desired date in 'Date', that falls in both provider's authorization begin and end date range from the setup.
  26. Click [Process].
  27. Verify that the report generated with all the active service authorizations for 'Provider 1' and 'Provider 2'.
  28. Click [Close Report].
  29. Click [Yes].
  30. Enter any desired date in 'Date', that falls outside both provider's authorization begin and end date range from the setup.
  31. Click [Process].
  32. Verify that the report generated shows 'No Data Found For Report'.
  33. Click [Close Report].
  34. Click [No].
Topics
• Contracting Provider Service Authorization • Service Authorizations
Update 23 Summary | Details
MSO - Active Member Enrollment
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Active Member Enrollment
  • Member Enrollment
Scenario 1: Active Member Enrollment - Report
Specific Setup:

  • Funding Source 1:
  • An active funding source is created or identified.
  • Provider 1:
  • An active contracting provider is created or identified.
  • Client A:
  • A new client is created or an existing one is identified and admitted to any Inpatient/ Outpatient program.
  • Has an active diagnosis record.
  • Financial Eligibility:
  • 'Guarantor 1' is filed as the primary guarantor for 'Client A'.
  • Note the 'Policy Number'.
Steps
  1. Open 'Registry Settings'.
  2. Search and select 'Require Member Enrollment' Registry Setting.
  3. Set the value to "Y".
  4. Click [Submit].
  5. Click [OK].
  6. Click [No].
  7. Refresh the forms from the User Menu.
  8. Open 'User Definition' and add the 'Member Enrollment' form to access.
  9. Refresh the forms from the User Menu.
  10. Open 'Member Enrollment'.
  11. Select 'Client A'.
  12. Verify that the form loads with the data of 'Client A'.
  13. Enter the desired date value in the 'Effective Date Of Enrollment' field.
  14. Enter the 'Provider 1' in the 'Primary Contracting Provider' field.
  15. Select 'Funding Source 1'.
  16. Validate that the 'Plan' field populates the value of the selected funding source.
  17. Set the 'Funding Source Policy Number' field with the 'Policy Number' from setup.
  18. Click [Submit].
  19. Open 'Active Member Enrollment'.
  20. Verify that the form has the below fields:
  21. Select Funding Source - Leave Blank For All:
  22. Is not required and enabled.
  23. Enter Report Run Date:
  24. Is required and enabled.
  25. Enter a future date in the 'Enter Report Run Date' field.
  26. Verify that a warning message displays: Future date entered.
  27. Click [OK].
  28. Click [Process].
  29. Verify that the report is generated with the data for 'Client A'.
  30. Verify that the report displays 'Fund Source(s)' as 'All'.
  31. Click [Close Report].
  32. Click [Yes].
  33. Enter 'Funding Source 1' in the 'Select Funding Source - Leave Blank For All' field.
  34. Click [Process].
  35. Verify that the report is generated with the data for 'Client A'.
  36. Verify that the report displays 'Fund Source(s)' as 'Funding Source 1'.
  37. Click [Close Report].
  38. Click [Yes].
  39. Enter any desired date that is before the member's enrollment date.
  40. Click [Process].
  41. Verify that the report is generated and does not have data for 'Client A'.
  42. Click [No].
  43. Open 'Registry Settings'.
  44. Search and select 'Require Member Enrollment' Registry Setting.
  45. Set the value to "N".
  46. Click [Submit].
  47. Click [OK].
  48. Click [No].
MSO - Batch Display
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Batch Display
Scenario 1: Batch Display - Report
Specific Setup:
  • System with:
  • Minimum of one batch with approved service(s).
  • Batch 1
  • Minimum of one batch with denied service(s).
  • Batch 2
Steps
  1. Open 'Batch Display'.
  2. Verify that the form has the below field:
  3. Select Batch Number - Leave Blank For All Batches.
  4. Is not required and enabled.
  5. Select 'Batch 1' in the 'Select Batch Number - Leave Blank For All Batches' field.
  6. Click [Process].
  7. Verify that the report is generated with the 'Batch 1' data.
  8. Click [Close Report].
  9. Click [Yes].
  10. Clear the 'Select Batch Number - Leave Blank For All Batches' field value and set it to empty.
  11. Click [Process].
  12. Verify that the report is generated and has the data for both 'Batch 1' and 'Batch 2'.
  13. Click [Close Report].
  14. Click [No].
MSO - Care Manager's Denied Authorizations
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Care Manager's Denied Authorizations
Scenario 1: Care Manager's Denied Authorizations - Report
Specific Setup:
  • Service Authorization:
  • Has an active service authorization for the below combination:
  • Funding source
  • Provider
  • Benefit plan
  • Begin date of authorization
  • End date of authorization
  • The 'Current Authorization Status' is set to 'Denied' with a reason selected.
  • A 'Care Manager' is assigned with the 'Date Care Manager Assigned' value selected.
  • System has a minimum of two service(s) denied due to the below reason:
  • Service(s) entered are filed as denied by the care manager assigned in the service authorization.
Steps
  1. Open 'Care Manager's Denied Authorizations'.
  2. Verify that the form has the below fields:
  3. Select Care Manager - Leave Blank For All Care Managers:
  4. Is not required and enabled.
  5. Authorization Effective Date:
  6. Is required and enabled.
  7. Enter any desired future date.
  8. Verify that the warning message displays: "Future date entered".
  9. Click [Cancel].
  10. Verify that the field is reverted to blank.
  11. Enter any desired future date, that is outside of the Authorization's begin and end date from the setup.
  12. Click [OK] in the future date warning message.
  13. Verify that the date entered is retained.
  14. Click [Process].
  15. Verify that the report is generated with no data, within the entered date range.
  16. Verify that the report displays 'All Care Managers'.
  17. Click [Close Report].
  18. Click [Yes].
  19. Enter any desired date, that is within the Authorization's begin and end date from the setup.
  20. Click [Process].
  21. Verify that the report is generated with the denied services data for all care managers, within the entered date range.
  22. Verify that the report displays 'All Care Managers'.
  23. Click [Close Report].
  24. Click [Yes].
  25. Select the care manager from the setup in the field 'Select Care Manager - Leave Blank For All Care Managers'.
  26. Click [Process].
  27. Verify that the report is generated with the denied services data for the care manager selected, within the entered date range.
  28. Verify that the report shows the care manager's ID in the header section.
  29. Click [Close Report].
  30. Click [No].
MSO - Denied Services By Procedure Code
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Denied Services By Procedure Code
Scenario 1: Denied Services By Procedure Code - Report
Specific Setup:
  • System has a minimum of five service(s) denied due to the below reason:
  • Service unit(s) entered exceeds the permitted amount of units filed in the service authorization of the respective procedure code.
Steps
  1. Open 'Denied Services By Procedure Code'.
  2. Verify that the form has the below field(s):
  3. Select Provider - Leave Blank For All Providers:
  4. Is not required and enabled.
  5. Include Services On Or After:
  6. Is required and enabled.
  7. Up To And Including"
  8. Is required and enabled.
  9. Leave all the fields empty.
  10. Click [Process].
  11. Verify an error message displays: "The following fields are missing: Include Service On Or After Up To And Including".
  12. Click [OK].
  13. Enter the desired date for 'Include Services On Or After date'.
  14. Enter a future date for 'Up To And Including date'.
  15. Verify the warning message displays: "Future date entered".
  16. Click [OK].
  17. Verify that the field is retained with the entered date.
  18. Enter any different future date for 'Up To And Including date'.
  19. Verify the warning message displays: "Future date entered".
  20. Click [Cancel].
  21. Verify that the field is reverted to the date that was not cancelled.
  22. Click [Process].
  23. Verify that the report is generated with the denied services data, within the entered date range.
  24. Verify that the report displays 'All Providers'.
  25. Click [Close Report].
  26. Click [Yes].
  27. Select the provider value of the services from the setup.
  28. Click [Process].
  29. Verify that the report is generated with the denied services data for the selected provider, within the entered date range.
  30. Verify that the report displays the specific Provider's Number.
  31. Click [Close Report].
  32. Click [No].
Topics
• Member Enrollment • Database Management • Claims Processing • Service Authorizations
Update 26 Summary | Details
SYSTEM.billing_837p_claim_data and SYSTEM.billing_837p_service_data - Field validation
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • Financial Eligibility
  • CPT Code Definition (PM)
  • Funding Source Registration
  • CPT Code Definition (MSO)
  • Performing Provider Registration
  • Contracting Provider Registration
Scenario 1: 837 Health Care Claim Professional - Supervising practitioner information included in 2310D loop – Validating ‘SYSTEM.billing_837p_claim_data’ and an outbound 837 Professional bill
Specific Setup:
  • Admission:
  • An existing outpatient 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 active diagnosis record is created for the client. Note the diagnosis date and diagnosis code.
  • CPT Code Definition:
  • Identify an existing CPT code or create a new CPT code. Note the CPT code/description.
  • Funding Source Registration:
  • Identify an existing funding source or create a new funding source. Note the funding source / registration date.
  • Plan Definition:
  • Identify an existing plan definition for the funding source identified or create a new plan definition. Note the plan id, name, and effective date.
  • Provider Fee Definition:
  • New fee definition is created for the member and provider for the identified CPT code. Note the effective date.
  • Member Specific Information:
  • Member and funding source specific information are added in this form.
  • Service Authorization:
  • An approved authorization is created for the client identified above. Note the authorization number for later use.
  • Batch Creation:
  • New batch is created for the service entry. Note the batch number for later use.
  • 837 Professional format inbound file for compilation and posting which contains NM1*DQ segment at the claim level. Note the name/location path of the file.
Steps
  1. Open the '837 Health Care Claim Professional' form.
  2. Select "Load File" from the 'Options' field.
  3. Set the File Path\Name text field to the desired path where an inbound 837 professional file is located that contains an 2420D-NM1-DQ segment and matched to the clients/episodes in Avatar MSO. Note the name of the file.
  4. Click [Process].
  5. Verify the crystal report lunched successfully.
  6. Verify that the report displays all the data from the file.
  7. Click [x].
  8. Select "Compile File" from the 'Options' field.
  9. Set the 'Date Claims Received' to desired date.
  10. Select the recently loaded file from the 'Select File' dropdown list.
  11. Click [Process].
  12. Verify the file compiles successfully and the crystal report lunched successfully.
  13. Verify that all the claims/services approved and included correctly in the report.
  14. Close the report.
  15. Select "Post File" from the 'Options' field.
  16. Set the 'Date Claims Received' to desired date.
  17. Select the recently compiled file from the 'Select File' dropdown list.
  18. Click [Process].
  19. Verify the file posts successfully and the crystal report lunched successfully.
  20. Verify that all the claims/services approved and included correctly in the report.
  21. Close the report.
  22. Close the form.
  23. Open the 'Crystal Report' or any other SQL Data Viewer.
  24. Locate to the MSO namespace of the system.
  25. Query 'Select * from SYSTEM.billing_837p_claim_data'.
  26. Validate the 'sup_prov_code_qualif' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  27. Validate the 'sup_prov_first_name' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  28. Validate the 'sup_prov_identifier' cell is equal to the value added for this item in the 837 Health Care Claim Professional file.
  29. Validate the 'sup_prov_last_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  30. Validate the 'sup_prov_mid_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  31. Close The Application.
Scenario 2: 837 Health Care Claim Professional - Supervising practitioner information included in 2420D loop – Validating ‘SYSTEM.billing_837p_service_data’ (Cal-PM /PM side)
Specific Setup:
  • Admission:
  • An existing outpatient 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 active diagnosis record is created for the client. Note the diagnosis date and diagnosis code.
  • CPT Code Definition:
  • Identify an existing CPT code or create a new CPT code. Note the CPT code/description.
  • Funding Source Registration:
  • Identify an existing funding source or create a new funding source. Note the funding source / registration date.
  • Plan Definition:
  • Identify an existing plan definition for the funding source identified or create a new plan definition. Note the plan id, name, and effective date.
  • Provider Fee Definition:
  • New fee definition is created for the member and provider for the identified CPT code. Note the effective date.
  • Member Specific Information:
  • Member and funding source specific information are added in this form.
  • Approve/Pend/Deny Rules Definition:
  • A definition is created for an existing funding source and the 'Duplicate Service Found' is set to 'Deny'.
  • Member ID' is checked in the 'Duplicate Service' parameters.
  • Service Authorization:
  • An approved authorization is created for the client identified above. Note the authorization number for later use.
  • Batch Creation:
  • New batch is created for the service entry. Note the batch number for later use.
  • 837 Professional format inbound file is created that have supervising practitioner information included in 2310D and/or 2420D segments. That contains an 2310D-NM1-DQ and 2420D-NM1-DQ segments and matched to the clients/episodes in Avatar MSO. Note the name/location path of the file.
Steps
  1. Open the '837 Health Care Claim Professional' form.
  2. Select "Load File" from the 'Options' field.
  3. Set the 'File Path\Name' text field to the desired path where an inbound 837 professional file is located that contains an 2420D-NM1-DQ segment and matched to the clients/episodes in Avatar MSO. Note the name of the file.
  4. Click [Process].
  5. Verify the crystal report lunched successfully.
  6. Verify that the report displays all the data from the file.
  7. Click [x].
  8. Select "Compile File" from the 'Options' field.
  9. Set the 'Date Claims Received' to desired date.
  10. Select the recently loaded file from the 'Select File' dropdown list.
  11. Click [Process].
  12. Verify the file compiles successfully and the crystal report lunched successfully.
  13. Verify that all the claims/services approved and included correctly in the report.
  14. Close the report.
  15. Select "Post File" from the 'Options' field.
  16. Set the 'Date Claims Received' to desired date.
  17. Select the recently compiled file from the 'Select File' dropdown list.
  18. Click [Process].
  19. Verify the file posts successfully and the crystal report lunched successfully.
  20. Verify that all the claims/services approved and included correctly in the report.
  21. Close the report.
  22. Close the form.
  23. Open the 'Crystal Report' or any other SQL Data Viewer.
  24. Locate to the MSO namespace of the system.
  25. Query 'Select * from SYSTEM.billing_837p_service_data'.
  26. Validate the 'sup_prov_code_qualif' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  27. Validate the 'sup_prov_first_name' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  28. Validate the 'sup_prov_identifier' cell is equal to the value added for this item in the 837 Health Care Claim Professional file.
  29. Validate the 'sup_prov_last_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  30. Validate the 'sup_prov_mid_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  31. Close The Application.
Topics
• Database Management • 837 Health Care Claim Professional • 837 Professional
Update 28 Summary | Details
MSO - Services paid within 30 days
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Services paid within 30 days
Scenario 1: Services paid within 30 days report
Specific Setup:
  • 'Client A':
  • A new client is created or an existing one is identified and admitted to any Inpatient/ Outpatient program.
  • Has active diagnosis and financial eligibility records.
  • 'Funding Source 1':
  • An active funding source is created or identified.
  • 'Provider 1':
  • An active contracting provider is created or identified.
  • 'Provider 2':
  • An active contracting provider is created or identified.
  • Service Authorization(s):
  • For 'Client A' there are active service authorization records with valid begin and end dates for 'Provider 1' and 'Provider 2'.
  • Claim Processing:
  • Services are created in different batches for 'Provider 1' and 'Provider 2'.
  • The respective batches are closed.
  • EOB:
  • EOB's are created for the above services.
Steps
  1. Open 'Services Paid Within 30 Days'.
  2. Verify that the form has the below fields:
  3. Individual or All Contracting Providers:
  4. Is required and enabled.
  5. Contracting Provider:
  6. This field is required or not based on the selected value in 'Individual or All Providers'.
  7. When 'Individual' is selected in 'Individual or All Providers' then it is required and enabled.
  8. When 'All' is selected in 'Individual or All Providers' then it is not required and disabled.
  9. From Date:
  10. Is required and enabled.
  11. Through Date:
  12. Is required and enabled.
  13. Leave all the required fields empty and click [Process].
  14. Verify an error message displays for the missing mandatory fields.
  15. Click [OK].
  16. Select 'Individual' in the 'Individual or All Contracting Providers' field.
  17. Click [Process].
  18. Verify an error message displays for the missing mandatory fields.
  19. Click [OK].
  20. Select 'Provider 1'.
  21. Enter any desired 'From Date' and 'Through Date', that does not cover the 'Provider 1' services from setup.
  22. Click [Process].
  23. Verify that the report generated has 'No Data Found For Report'.
  24. Click [Close Report].
  25. Click [Yes].
  26. Enter any desired 'From Date' and 'Through Date', that covers the 'Provider 1' services from setup.
  27. Click [Process].
  28. Verify that the report contains 'Provider 1' data within the entered date range.
  29. Click [Close Report].
  30. Click [Yes].
  31. Select 'All' in the 'Individual or All Contracting Providers' field.
  32. Enter any desired date in 'Date', that falls in both 'Provider 1' and 'Provider 2' authorization begin and end date range from setup.
  33. Click [Process].
  34. Verify that the report contains 'Provider 1' and 'Provider 2' data within the entered date range.
  35. Click [Close Report].
  36. Click [No].
Topics
• Create EOB • Reports • Create Voucher • Service Authorizations
Update 29 Summary | Details
MSO - Member by Authorized Provider
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Members By Authorized Provider
Scenario 1: Members By Authorized Provider
Specific Setup:
  • 'Client A':
  • A new client is created or an existing one is identified and admitted to any Inpatient/ Outpatient program.
  • Has active diagnosis and financial eligibility records.
  • 'Funding Source 1':
  • An active funding source is created or identified.
  • 'Provider 1':
  • An active contracting provider is created or identified.
  • 'Provider 2':
  • An active contracting provider is created or identified.
  • Service Authorization(s):
  • For 'Client A' there are active service authorization records with valid begin and end dates, for 'Provider 1' and 'Provider 2'.
Steps
  1. Open 'Members By Authorized Provider'.
  2. Verify that the form has the following fields:
  3. Individual or All Providers:
  4. Is required and enabled.
  5. Provider:
  6. Verify this field is required or not based on the selected value in 'Individual or All Providers'.
  7. When 'Individual' is selected in 'Individual or All Providers' then it is required and enabled.
  8. When 'All' is selected in 'Individual or All Providers' then it is not required and disabled.
  9. Date:
  10. Is required and enabled.
  11. Leave all the required fields empty and click [Process].
  12. Verify the message displays for the missing mandatory fields.
  13. Click [OK].
  14. Select 'Individual' in the 'Individual or All Providers' field.
  15. Click [Process].
  16. Verify the message displays for the missing mandatory fields.
  17. Click [OK].
  18. Select 'Provider 1'.
  19. Enter any desired date in 'Date', that falls outside the 'Provider 1' authorization begin and end date range from the setup.
  20. Click [Process].
  21. Verify that the report generated contains 'No Data Found For Report'.
  22. Click [Close Report].
  23. Click [Yes].
  24. Enter any desired date in 'Date', that falls in the 'Provider 1' authorization begin and end date range from the setup.
  25. Click [Process].
  26. Verify that the report contains the members details with the active service authorizations for 'Provider 1'.
  27. Click [Close Report].
  28. Click [Yes].
  29. Select 'All' in the 'Individual or All Providers' field.
  30. Enter any desired date in 'Date', that falls in both 'Provider 1' and 'Provider 2' authorization begin and end date range from the setup.
  31. Click [Process].
  32. Verify that the report contains the members details with the active service authorizations for 'Provider 1' and 'Provider 2'.
  33. Click [Close Report].
  34. Click [No].
MSO - Paid Services by Procedure Code
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Paid Services By Procedure Code
Scenario 1: Paid Services By Procedure Code report
Specific Setup:
  • 'Client A':
  • A new client is created, or an existing one is identified and admitted to any Inpatient/ Outpatient program.
  • Has active diagnosis and financial eligibility records.
  • 'Funding Source 1':
  • An active funding source is created or identified.
  • 'Provider 1':
  • An active contracting provider is created or identified.
  • 'Provider 2':
  • An active contracting provider is created or identified.
  • Service Authorization:
  • For 'Client A' there are active service authorization records with valid begin and end dates, for 'Provider 1' and 'Provider 2'.
  • Claim Processing:
  • Services are created in different batches for 'Provider 1' and 'Provider 2'.
  • The respective batches are closed.
  • EOB:
  • EOB's are created for the above services.
Steps
  1. Open 'Paid Services By Procedure Code'.
  2. Verify that the form has the following fields:
  3. Individual or All Providers:
  4. Is required and enabled.
  5. Provider:
  6. Verify this field is required or not based on the selected value in 'Individual or All Providers'.
  7. When 'Individual' is selected in 'Individual or All Providers' then it is required and enabled.
  8. When 'All' is selected in 'Individual or All Providers' then it is not required and disabled.
  9. From Date:
  10. Is required and enabled.
  11. Through Date:
  12. Is required and enabled.
  13. Leave all the required fields empty and click [Process].
  14. Verify the message displays for the missing mandatory fields.
  15. Click [OK].
  16. Select 'Individual' in the 'Individual or All Providers' field.
  17. Click [Process].
  18. Verify the message displays for the missing mandatory fields.
  19. Click [OK].
  20. Select 'Provider 1'.
  21. Enter any desired 'From Date' and 'Through Date', that does not cover the 'Provider 1' service(s) from the setup.
  22. Click [Process].
  23. Verify that the report contains 'No Data Found For Report'.
  24. Click [Close Report].
  25. Click [Yes].
  26. Enter any desired 'From Date' and 'Through Date', that covers the 'Provider 1' service(s) from the setup.
  27. Click [Process].
  28. Verify that the report contains the service details of the members with 'Provider 1' that are paid within the entered date range.
  29. Click [Close Report].
  30. Click [Yes].
  31. Select 'All' in the 'Individual or All Providers' field.
  32. Enter any desired date in 'Date', that falls in both 'Provider 1' and 'Provider 2' authorization begin and end date range from the setup.
  33. Click [Process].
  34. Verify that the report contains the service details of the members with 'Provider 1' and 'Provider 2' that are paid within the entered date range.
  35. Click [Close Report].
  36. Click [No].
Topics
• Contracting Provider Service Authorization • Member Enrollment • Service Authorizations • Create EOB • Create Voucher
 

Avatar_MSO_2024_Monthly_Release_2024.02.00_Details.csv