Avatar MSO 2024 Quarterly Release 2024.02 Acceptance Tests

• Field 'Number of Services Per Claim Allowed' in Avatar MSO 'Approve/Pend/Deny Rules Definition' form must be defined
• Field 'Number of Services Per Claim Allowed Exceeded' in Avatar MSO 'Approve/Pend/Deny Rules Definition' form must be defined
• Two or more client records eligible for claim/service entry

1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
3. Navigate to 'Fast Service Detail' section of form.
4. Click 'Add New Item' button to enter new service.
5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
6. Enter/select values in all other service detail fields in form as required/desired.
7. Click 'Add New Item' button.
8. Enter/select service entry information values, using different/distinct Client ID in the 'Member Name or ID' field.
9. Select value for 'Authorization Number' field.
10. Ensure that in case where 'Member Name or ID' differs between service rows entered in 'Fast Service Entry' form, services not exceeding the 'Number of Services Per Claim Allowed' setting are not incorrectly denied with adjudication reason 'Number of services per claim allowed exceeded' in case where services for different/distinct clients do not exceed limit.
11. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
12. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).

• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Approve/Pend/Deny Rules Definition' form.
2. Select Funding Source for Approve/Pend/Deny Rules Definition entry/edit.
3. Ensure the following fields are present in the 'Approve/Pend/Deny Rules Definition' form:
4. 'Rule Coverage Period'
5. Dropdown selection field including existing A/P/D Rule Coverage Periods as well as 'Create New' selection
6. On installation of Avatar MSO 2024 Update 2, a default A/P/D Rule Coverage Period entry with 'Start Date' of '1/1/1990' and no 'End Date' value is defined for each/all Funding Sources based on Approve/Pend/Deny Rules Definition information existing prior to update (to allow for Claim Processing/Service Adjudication under same A/P/D Rule conditions as defined prior to update for all services).
7. 'Start Date'
8. Start Date for A/P/D Rule Coverage Period (required); services with 'Date of Service' on or after this date will be adjudicated according to A/P/D rules defined for this Rule Coverage Period
9. 'End Date'
10. End Date for A/P/D Rule Coverage Period; services (not required); if defined, services with 'Date of Service' on or before this date will be adjudicated according to A/P/D rules defined for this Rule Coverage Period
11. If 'End Date' is not defined, A/P/D Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
12. Select existing A/P/D Rule Coverage Period for edit/review, or select 'Create New' for new A/P/D Rule Coverage Period entry.
13. Enter value for 'Start Date' field (and 'End Date' if desired).
14. Enter/select values for all Approve/Pend/Deny Rule fields/settings as required/desired.
15. Click 'Submit' button to file Approve/Pend/Deny Rules Definition' form/Rule Coverage Period information.
16. In case where Rule Coverage Period 'Start Date'/'End Date' values overlap another Rule Coverage Period defined for the same Funding Source - Ensure that user is presented with an error dialog noting 'Date ranges are overlapping, please adjust dates appropriately', submission/filing is canceled and user is returned to form to correct overlapping dates
17. In case where Rule Coverage Period 'End Date' value is prior to 'Start Date' value - Ensure that user is presented with an error dialog noting 'End Date needs to be the same day or later than Start Date', submission/filing is canceled and user is returned to form to correct invalid dates
18. Re-open 'Approve/Pend/Deny Rules Definition' form.
19. In 'Rule Coverage Period', ensure all previously entered/filed Rule Coverage Periods are available for selection.
20. Select existing A/P/D Rule Coverage Period for edit/review.
21. Ensure that previously entered/selected values for all Approve/Pend/Deny Rule fields are present in form for selected A/P/D Rule Coverage Period.
22. Open Crystal Reports or other SQL reporting tool.
23. In Avatar MSO SQL table 'SYSTEM.apd_rule_def', ensure that Approve/Pend/Deny Rule field values/information are present for all A/P/D Rule Coverage Periods entered/filed in Avatar MSO.
24. Note - Avatar MSO SQL table 'SYSTEM.table_app_pen_den_rules' is no longer used for storage of 'Approve/Pend/Deny Rules Definition' form information and will not reflect/include any information filed after Avatar MSO 2024 Update 2 installation; all updated/added 'Approve/Pend/Deny Rules Definition' form information will be filed/stored in Avatar MSO SQL table 'SYSTEM.apd_rule_def'

• Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• 837 Health Care Claim Professional file with one or more valid claims

1. Open Avatar MSO '837 Health Care Claim Professional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Professional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
6. Click 'Process' button.
7. In 837 Professional Compile Report - ensure that one or more claims/services are successfully compiled.
8. Select 'Post File' in the 'Options' field.
9. Select compiled 837 Professional format file and click 'Process' button.
10. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
11. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
12. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
13. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
14. Examples:
15. 'The service was approved with the following notices: Maximum Number Of Units Of Procedure Code Per Day Exhausted. Invalid Measurement Code for Procedure Code. Location's Place of Service Is Invalid For Procedure Code. Limited by total charge'
16. 'The service was denied for the following reasons: Specified Duration is not valid for Procedure Code. Invalid Measurement Code for Procedure Code. The service also has the following Approval notices: Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Claim Submitted with a Date Range'
17. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
18. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
19. Note - Select claim processing/service adjudication Approve/Pend/Deny rules/functionality occurs within the system batch/claim adjudication process (and not in 837 inbound file compilation/posting). Avatar MSO Claim Processing batch(es) must be adjudicated following 837 file posting in order for services to reflect all Approve/Pend/Deny rules/adjudication 'Explanation of Coverage', 'Expected Disbursement' and 'Approved Units' values

• Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• 837 Health Care Claim Institutional file with one or more valid claims

1. Open Avatar MSO '837 Health Care Claim Institutional' form.
2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
3. Select 'Load File' in the 'Options' field.
4. Enter file path for inbound 837 Institutional format file and click 'Process' button.
5. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
6. Click 'Process' button.
7. In 837 Institutional Compile Report - ensure that one or more claims/services are successfully compiled.
8. Select 'Post File' in the 'Options' field.
9. Select compiled 837 Institutional format file and click 'Process' button.
10. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
11. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
12. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
13. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
14. Examples:
15. 'The service was approved with the following notices: Maximum Number Of Units Of Procedure Code Per Day Exhausted. Invalid Measurement Code for Procedure Code. Location's Place of Service Is Invalid For Procedure Code. Limited by total charge'
16. 'The service was denied for the following reasons: Specified Duration is not valid for Procedure Code. Invalid Measurement Code for Procedure Code. The service also has the following Approval notices: Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Claim Submitted with a Date Range'
17. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
18. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
19. Note - Select claim processing/service adjudication Approve/Pend/Deny rules/functionality occurs within the system batch/claim adjudication process (and not in 837 inbound file compilation/posting). Avatar MSO Claim Processing batch(es) must be adjudicated following 837 file posting in order for services to reflect all Approve/Pend/Deny rules/adjudication 'Explanation of Coverage', 'Expected Disbursement' and 'Approved Units' values

• Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• Client record eligible for claim/service entry

1. Enter one or more claims/services in Avatar MSO using Funding Source where one or more Approve/Pend/Deny Rule Coverage Period(s) are defined in system.
2. Note - Claim/Service entry may be done via 'Fast Service Entry'/'Claim Processing (CMS 1500)' forms and/or '837 Health Care Claim Professional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
3. During or following batch/claim/service entry - open claims/services for review via 'Claim Processing (CMS 1500)' (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
4. Navigate to 'Service Detail' section of form.
5. Select service row and click 'Edit Selected Item'.
6. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
7. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
8. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
9. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
10. Examples:
11. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
12. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
13. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
14. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.

• Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• Client record eligible for claim/service entry

1. Enter one or more claims/services in Avatar MSO using Funding Source where one or more Approve/Pend/Deny Rule Coverage Period(s) are defined in system.
2. Note - Claim/Service entry may be done via 'Claim Processing (UB-04)' form and/or '837 Health Care Claim Institutional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
3. During or following batch/claim/service entry - open claims/services for review via 'Claim Processing (UB-04)' (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
4. Navigate to 'Service Detail' section of form.
5. Select service row and click 'Edit Selected Item'.
6. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
7. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
8. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
9. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
10. Examples:
11. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
12. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
13. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
14. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.

• Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• Client record eligible for claim/service entry

1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
3. Navigate to 'Fast Service Detail' section of form.
4. Click 'Add New Item' button to enter new service.
5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
6. Enter/select values in all other service detail fields in form as required/desired.
7. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
8. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
9. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
10. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
11. Examples:
12. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
13. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
14. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
15. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
16. On editing one or more service detail field values related to claim adjudication/status (including 'Date of Service') - ensure that 'Claim Status'/'Explanation of Coverage' information is re-processed using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (and claim/service adjudication status and information updated accordingly).
17. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
18. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).

• Avatar MSO Registry Setting 'Enable Contracting Provider Program' must be enabled
• CPT Code where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included (via Avatar 'Provider Fee Definition' form)
• Client record eligible for claim/service entry

1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
3. Navigate to 'Fast Service Detail' section of form.
4. Click 'Add New Item' button to enter new service.
5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', and 'Contracting Provider Program' fields.
6. Select value in 'Procedure Code' field, selecting CPT Code where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included.
7. Ensure that in case where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included for the selected CPT Code/Procedure Code, user is not incorrectly presented with dialog noting 'Procedure Not On Fee Schedule'.
8. Enter/select values in 'Total Charge', 'Service Units' and 'Authorization Number' fields, as well all other service detail fields as required/desired.
9. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
10. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).

• Avatar Cal-PM Parent System is required for Acceptance Testing with Registry Setting 'Support MSO Other Healthcare Coverage' enabled
• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (set to '1','2', '3' or '4')
• If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• CPT Code/Revenue Code must be selected/included for Fee Override in filing to parent system (via Avatar 'Provider Fee Definition' form)
• One or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information

1. Open Avatar MSO 'Close Batch' form.
2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
6. Open 'Client Ledger' form in parent Avatar Cal-PM system.
7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
8. Select 'Claim/Episode/All Episodes' value.
9. Select 'Ledger Type' value.
10. Click 'Process' button.
11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
12. For services originating via Avatar MSO and filed to Avatar Cal-PM parent system (where Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' and Avatar MSO Registry Setting 'Enable Fee Override in PM' are enabled):
13. Services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM Client Ledger 'Charge' value for service(s) reflects the 'Allowed Amount' value (or 'Expected Disbursement' value if differing) from Avatar MSO Other Healthcare Coverage information for service(s)
14. Note - In case where PM Service Fee Table Amount is selected for parent system service filing, services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information will use Avatar MSO Allowed Amount/Expected Disbursement service value for Cal-PM parent service 'Cost of Service'/'Guarantor Liability' (to ensure correctly balanced Avatar Cal-PM outbound 837 claim information where Other Healthcare Coverage information is included in original claim/service)
15. Note - Avatar Cal-PM 'Cost of Service'/'Guarantor Liability' value for service(s) originating in Avatar MSO with Other Healthcare Coverage information will reflect Client Ledger Charge/Allowed Amount/Expected Disbursement value not including Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM
16. Services not including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM 'Charge'/'Cost Of Service' (as well as 'Guarantor Liability') value for service(s) in Avatar Cal-PM reflects the selected/applicable Avatar MSO Fee Override Type (Expected Disbursement/Fee Table Amount/Total Charge), or PM Service Fee Table Amount where override not selected

• Avatar ProviderConnect MSO solution must be present/installed
• 'ProviderConnect File Attach Defaults' form settings/values must be defined
• One or more client records with existing ProviderConnect File Attach attachment records and eligible for 'Client Merge' filing

1. Open Avatar PM/Cal-PM 'Client Merge' form.
2. Select 'Source Client ID', using client with existing ProviderConnect File Attach attachment record(s).
3. Select value for 'Merge All Client Data Through Single Filing' field (and select 'Non-Episodic Data' as 'Source Client Episode' value if applicable).
4. Select 'Target Client ID'.
5. Click 'File' button, and click 'Yes' button in the 'Do You Wish To Continue With The Indicated Action?' dialog.
6. Ensure that merge verification dialog is presented on completion of merge.
7. Open Avatar MSO 'ProviderConnect File Attach' form.
8. Select 'Member ID' value, using 'Target Client ID' value from Client Merge filing.
9. Select 'Provider' and 'File Type' values (and select 'Authorization' value if applicable).
10. Ensure that all ProviderConnect File Attach attachment files originally filed under 'Source Client ID' used in Client Merge are present/relocated to 'Target Client ID' record following non-episodic client data merge (including 'Provider' and 'Other' attachment types associated to Contracting Provider ID, as well as 'Authorization' attachment types associated to merged/relocated Service Authorization records).
11. Select existing/relocated ProviderConnect File Attach attachment file and click 'View File' to display.

• One or more Contracting Provider Registration record(s) where Contracting Provider Program entry has been deleted
• One or more MSO Contracting Provider/Contracting Provider Program/Procedure Code to PM/Cal-PM Program mapping(s) where Contracting Provider Program entry used in mapping has been deleted (defined via 'MSO to Parent System Integration Mapping' form)

1. Open Avatar MSO 'MSO To Parent System Integration Mapping' form.
2. Navigate to 'Mapping Delete' section of form.
3. Within 'Mapping Delete' section of form, navigate to fields for MSO Contracting Provider/Contracting Provider Program/Procedure Code to PM/Cal-PM Program mapping deletion.
4. Enter/select values for 'Contracting Provider', 'Contracting Provider Program', 'Procedure Code' and 'Program' criteria fields.
5. Ensure all existing mappings for selected Contracting Provider/Contracting Provider Program/Procedure Code/Program criteria are listed/present in the 'Available Mapping(s)' field for selection/deletion.
6. Ensure that any previously existing and deleted Contracting Provider/Contracting Provider Program/Procedure Code/Program mappings are not listed/not present in 'Available Mapping(s)' field.
7. Select one or more mapping entries for deletion; click 'Delete' button to delete selected mapping(s).
8. Re-Enter/select values for 'Contracting Provider', 'Contracting Provider Program', 'Procedure Code' and 'Program' criteria fields.
9. Ensure deleted mapping entries are not listed/not present in 'Available Mapping(s)' field.

• File path for 277CA Claim Acknowledgement file creation must be defined in the 'Output Directory' field for system (via Avatar MSO 'Set System Defaults' or 'Import/Export File Configuration' form)
• 277CA Claim Acknowledgment file may optionally be enabled for automatic generation (via Avatar MSO 'Import/Export File Configuration' form)
• 837 Professional and/or Institutional format inbound file(s) for compilation/posting

1. Using Avatar MSO '837 Health Care Claim Professional' and/or '837 Health Care Claim Institutional' forms (or via Avatar MSO automated 837 file processing), load/compile/post inbound 837 file(s).
2. Open the Avatar MSO 'Claim Acknowledgement (277CA) File' form.
3. 277CA file generation/content review may also be confirmed directly in system output directory where automatic 277CA file generation is enabled
4. Select 'Create File On Server' in 'Options' field.
5. Select 'Submission Type' field value ('Institutional' or 'Professional').
6. Select 837 file for Claim Acknowledgement (277CA) file creation.
7. Click 'Process' button.
8. Ensure that for selected 837 file, Claim Acknowledgement (277CA) file is created on server in defined directory.
9. This may be confirmed via the 'Claim Acknowledgement (277CA) File' form 'Run Report' or 'Dump File' options, and/or by reviewing files in 277CA output directory
10. Select 'Dump File' in 'Options' field.
11. Select 'Submission Type' field value ('Institutional' or 'Professional').
12. Select 837 file for Claim Acknowledgement (277CA) file review.
13. Click 'Process' button.
14. 277CA file content review may also be confirmed directly in system output directory by opening/reviewing file(s).
15. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all services within claim are accepted by Avatar MSO, ensure that Claim level acceptance (2200D Claim Level Status Information) is reported with 'Accepted' status (A2).
16. Example:
17. STC*A2:20*20221005*WQ*500~
18. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all services within claim are rejected by Avatar MSO, ensure that Claim level acceptance (2200D Claim Level Status Information) is reported with 'Rejected' status (A7).
19. Example:
20. STC*A7:21*20221005*U*500******A7:454~
21. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where services within claim are both accepted and rejected by Avatar MSO (split claims), ensure that Claim level acceptance (2200D Claim Level Status Information) is reported with 'Acknowledged' status (A5).
22. Example:
23. STC*A5:0*20221005*U*500~
24. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all services within claim are accepted by Avatar MSO, ensure that Service level acceptance information (2220D Service Line Information/Service Line Level Status Information/Service Line Item Identification/Service Line Date) is not included/reported.
25. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all or individual services within claim are rejected by Avatar MSO, ensure that Service Line Information (2220D SVC) is included/reported for each individual service line within claim only for rejected services (accepted services not reported within 2220D SVC detail for 'split' claims).
26. Examples:
27. SVC*HC:H0004*100*****210~
28. SVC*NU:910*54*****8~
29. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all or individual services within claim are rejected by Avatar MSO, ensure that Service Line Level Status Information (2220D STC) is included/reported with 'Rejected' status (A7) for individual service line, only for rejected services (accepted services not reported within 2220D STC detail for 'split' claims).
30. Example:
31. STC*A7:21**U*******A7:455~
32. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional and/or Institutional inbound claims where all or individual services within claim are rejected by Avatar MSO, ensure that Service Line Item Identification (2220D REF) is included/reported for individual service line, only for rejected services (accepted services not reported within 2220D REF detail for 'split' claims).
33. If 2400 Service Line Item Reference Number (2400 REF) is included in inbound 837 Professional/Institutional claim/service information, this reference number will be reported in 277CA file 2220D REF Service Line Item Identification segment.
34. If 2400 Service Line Item Reference Number (2400 REF) is not included in inbound 837 Professional/Institutional claim/service information, the line sequence number (2400 LX) for the service line within claim will be reported in 277CA file 2220D REF Service Line Item Identification segment
35. Examples:
36. REF*FJ*CX74X66110.003~
37. REF*FJ*3~
38. In 277CA Claim Acknowledgement file(s) for compiled/processed 837 Professional inbound and/or Institutional inbound claims where all or individual services within claim are rejected by Avatar MSO, ensure that Service Line Date (2220D DTP) is included/reported for individual service line only for rejected services (accepted services not reported within 2220D DTP detail for 'split' claims).
39. Examples:
40. DTP*472*D8*20220915~
41. DTP*472*RD8*20220915-20220920~

• Avatar MSO Registry Setting 'Enable Coverage Effective Period' must be enabled
• NOTE - The 'Enable Coverage Effective Period' Registry Setting is a ONE WAY registry setting that can only be enabled. Once enabled, this Registry Setting cannot be disabled
• Avatar MSO Registry Setting 'Enable Eligibility Check' must be enabled
• Avatar MSO Registry Setting 'Require Exact Program Match' may optionally be enabled
• Avatar MSO Registry Setting 'Use Program For Episode Match' may optionally be enabled
• CPT Code/Revenue Code with two or more Coverage Periods defined, where CPT Code/Revenue Code Coverage Periods are mapped to Avatar PM/Cal-PM Service Codes (via Avatar MSO 'MSO To Parent System Integration Mapping' form)
• Avatar MSO to PM/Cal-PM Parent System Financial Eligibility check must be enabled for 'Validate via Financial Eligibility Record' with criteria defined (via Avatar MSO 'Funding Source/Guarantor Mapping' form, 'Eligibility Check' section)
• Client with eligible Service Authorization record(s) valid for Service Entry/Claim Processing

1. Enter one or more claims/services in Avatar MSO using CPT Code/Revenue Code where two or more Coverage Period entries/rows are defined in system, and where CPT Code/Revenue Code Coverage Periods are mapped to Avatar PM/Cal-PM Service Codes.
2. Note - Claim/Service entry may be done via 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms, '837 Health Care Claim Professional'/'837 Health Care Claim Institutional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
3. During or following batch/claim/service entry - open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
4. Navigate to 'Service Detail' section of form.
5. Select service row and click 'Edit Selected Item'.
6. Ensure that Parent System Financial Eligibility Claim Processing/Service Adjudication Approve/Pend/Deny check result for each service is determined according to Coverage Period for related CPT Code/Revenue Code compared to Financial Eligibility record/coverage information, based on date of service and parent system Service Code as defined in MSO CPT Code/Revenue Code to PM/Cal-PM Service Code mapping (via Avatar MSO 'MSO To Parent System Integration Mapping' form).
7. Note - Coverage Period related to service will be entry where 'Date of Service' is on or after 'Coverage Effective Date' and on or prior to 'Coverage Effective Date' for Coverage Effective Period where defined
8. Ensure that 'Claim Status'/'Claim Status Reason' fields are set to values selected for 'Claims Status'/'Claim Status Reason' Approve/Pend/Deny fields (via Avatar MSO 'Funding Source/Guarantor Mapping' form, 'Eligibility Check' section) where Financial Eligibility check for corresponding CPT Code/Revenue Code Coverage Period and parent system Service Code mapping is failed.

• Client record eligible for Service Authorization entry/update

1. Open Avatar MSO 'Service Authorization' form.
2. Enter/select Client ID for Service Authorization entry/update.
3. Click 'Add' button in 'Service Authorization' form pre-display for new record entry (or select existing Service Authorization row/record for update and click 'Edit' button).
4. Enter/select values for 'Funding Source Authorization Is For', 'Benefit Plan' and 'Provider To Be Authorized' fields.
5. Enter values for 'Begin Date of Authorization' and/or 'End Date Of Authorization' fields.
6. Enter/select values for service code information fields (and any other 'Service Authorization' form fields as required/desired).
7. Click 'Submit' button to file 'Service Authorization' form/record.
8. On re-opening of same record in 'Service Authorization' form, ensure that previously entered/filed values for all fields are present, including 'Funding Source Authorization Is For', 'Benefit Plan', 'Provider To Be Authorized' and 'Begin Date of Authorization'/'End Date Of Authorization' fields.

• 'BulkDataStoreUpdate' action must be enabled in Avatar system (via 'CareFabric Management' form)
• EOB record(s) eligible for 835 outbound file inclusion including one or more claims/services originating via Avatar MSO 837 inbound processing

1. Open Avatar MSO '835 Health Care Claim Payment/Advice' form.
2. Note - Acceptance testing may also be confirmed in 835 files created via Avatar MSO Claim Processing Automation functions
3. Select 'Sort File' in the 'Options' field.
4. Select 'Contracting Provider' value.
5. Select EOB(s) for 835 outbound file inclusion in the 'Select EOB(s)' field.
6. Click 'Process' button.
7. Ensure that '835 Health Care Claim Payment/Advice Report' is displayed following 835 sorting completion (and includes one or more successfully sorted claims/services for 835 file creation).
8. Open Avatar PM/Cal-PM 'CareFabric Monitor' form.
9. Enter values for 'From Date' and 'Through Date' fields (using dates which include 274 Provider Directory Provider Definition entry/edit).
10. Enter/select values for any other CareFabric Monitor fields as desired.
11. Click 'View Activity Log' button to display CareFabric Monitor report results.
12. In CareFabric Monitor report results - ensure that 'BulkDataStoreUpdate' Action/Out Activity is present for all Explanation Of Benefits information/835s generated in the Avatar MSO '835 Health Care Claim Payment/Advice' form for claims/services originating via Avatar MSO 837 inbound processing (activity is per claim with 835 remittance advice generated).

• Internal Testing Only

• Document Management Configuration must be defined for Cache Server or Perceptive (via Avatar PM / RADplus Utilities 'Document Management Defaults' form)
• Dictionary Codes may optionally be defined for 'Other Tabled Files' Data Element '(70007) Document Type' (via Avatar MSO 'Dictionary Update' form)
• 'Provider File Attach' Widget may optionally be assigned to Chart View Definition/Home View Definition/Client Dashboard View assigned to user (via 'View Definition' form / 'NX View Definition' form)
• Clinical Document Viewer/Document Management/All Documents Widgets may optionally be assigned to Chart View Definition/Home View Definition/Client Dashboard View assigned to user (via 'View Definition' form / 'NX View Definition' form)
• One or more .PDF (Adobe Portable Document Format) and/or .TIF (Tagged Image File Format) files for Provider File Attach upload/storage
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Provider File Attach' form (under 'Avatar MSO / Provider Management' menu).
2. Enter/select 'Member ID' value.
3. Enter/select 'Provider' value.
4. In 'File Type' field, ensure the following selections are available:
5. 'Authorization' (will link File Attachment to a specific Avatar MSO Service Authorization record for selected Provider)
6. 'Provider' (will link File Attachment to selected Provider)
7. 'Other' (will link File Attachment to selected Provider)
8. Select 'File Type' value (and 'Authorization' field value if applicable).
9. Select 'Document Type' value and/or enter 'Comments' value if desired.
10. Click 'Upload File' button, and select file for Provider Attachment upload/storage.
11. On completion of File Attachment upload, ensure 'File Name' field is populated with uploaded file name.
12. Click 'Store File' field to store File Attachment in Avatar MSO; ensure user is presented with confirmation dialog noting 'File successfully created'.
13. Click 'OK' button to return to 'Provider File Attach' form.
14. Select 'File Type' value for previously uploaded/stored File Attachment.
15. Ensure uploaded/stored File Attachment files are listed/available for selection in the 'Existing Files' field.
16. Close 'Provider File Attach' form.
17. Navigate to Home View, Chart View or Client Dashboard View where Avatar MSO 'Provider File Attach' Widget is assigned/present
18. Ensure that the 'Provider File Attach' Widget displays all uploaded/stored File Attachment files for selected/currently active Member ID/Client (one row in Widget display per File Attachment).
19. Navigate to Home View, Chart View or Client Dashboard View where one or more myAvatar Clinical Document Viewer/Document Management/All Documents Widgets is/are assigned/present
20. Ensure that the Clinical Document Viewer/Document Management/All Documents Widget displays all uploaded/stored File Attachment files where expected for selected/currently active Member ID/Client, including 'Form Name' value of 'Provider Document'.
21. Open Crystal Reports or other SQL reporting tool.
22. In Avatar PM/Avatar MSO SQL table 'DOCM.document_image', ensure that all uploaded/stored Provider File Attachment files are present in SQL table data (one row per File Attachment); ensure that 'formID' value for Provider File Attachment records is 'PCON' ('Provider Document').
23. Note - As 'formID' is used for 'Form Name' display in Clinical Document Viewer/Document Management/All Documents Widgets; on installation of RADPlus 2024 Update 34, all existing Provider File Attach related Document Management rows will be updated with 'formID' value 'PCON'
24. In Avatar MSO SQL table 'SYSTEM.file_attach_object', ensure that all uploaded/stored Provider File Attachment files are present in SQL table data (one row per File Attachment).
25. In Avatar MSO SQL table 'SYSTEM.file_attach_comments', ensure that all uploaded/stored Provider File Attachment 'Comments' field entries are present in SQL table data (one row per 'Comments' entry).

1. Open Avatar MSO 'MSO EOB Message Customization' form.
2. In 'Message Type' field, select 'Miscellaneous Rules'.
3. Ensure value/entry 'Procedure Code is not valid for this date of service' is available in the 'Message Rule' field; select 'Procedure Code is not valid for this date of service'.
4. The 'Procedure Code is not valid for this date of service' Miscellaneous Rule Message will be used for 'Explanation of Coverage' and resulting 837/835 adjustment code information in claim/service adjudication where check on authorization begin/end dates is failed when validating Service Authorization and Contracting Provider Service Authorizations by Plan (in conjunction with Avatar MSO Registry Settings 'Enable Service Authorization by Plan' and 'Enforce Adjudication for Authorization Dates When Authorizing by Plan').
5. Ensure 'Custom Message' value and/or 'Adjustment Code'/'Remark Code' values may be specified for Message Rule; enter/update values as desired.
6. Click 'File' button to save/file MSO EOB Message Customization form entry/details.
7. On re-selecting 'Procedure Code is not valid for this date of service' in 'Message Rule' field, ensure that all previously entered/filed values for 'Custom Message' value and/or 'Adjustment Code'/'Remark Code' fields are present in form.

1. Open 'Registry Settings' form.
2. Enter search value 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Set Batch File Naming Convention' is returned (under 'Avatar MSO-> Care Management -> Service Authorization' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting "Y" will enforce the system during claim processing to validate that the Date of Service falls within the effective date range of the reported or associated Authorization when that Service or Contracting Provider Authorization has been authorized by the Plan Definition.

Selecting "N" will enforce the system during claim processing to validate that the date of Services falls within the effective date range of the Plan Definition selected in the reported or associated Service or Contracting Provider Authorization.

To enable this registry setting, the setting 'Enable Service Authorization by Plan' must be set to "Y"."

Note - Explanation text/'Registry Setting Details' field contents for Avatar MSO Registry Setting 'Enable Service Authorization By Plan' has also been updated as follows:

"Selecting 'Y' will add "All" as a choice for the field 'Authorization Grouping Or Individual Authorizations' on both the 'Service Authorization' and 'Contracting Provider Service Authorization' forms. When "All" is selected for an authorization, the authorization will cover all services defined within the plan. When this is set to 'Y', during claim processing, the system will validate the Date of Service against the effective dates of the authorized Plan Definition. To validate the Date of Service against the effective dates within the reported Authorization, the registry setting "Enforce Adjudication for Authorization Dates When Authorizing by Plan" must also be enabled.

Selecting 'N' will remove "All" as a choice for the field 'Authorization Grouping Or Individual Authorizations' on both the 'Service Authorization' and 'Contracting Provider Service Authorization' forms."

• Avatar MSO Registry Setting 'Enable Service Authorization By Plan' must be enabled
• Avatar MSO Registry Setting 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' must be enabled
• Client with eligible Service Authorization record and/or Contracting Provider Service Authorization record valid for Service Entry/Claim Processing, where 'All' is selected for 'Authorization Grouping Or Individual Authorizations' field

1. Enter one or more claims/services in Avatar MSO, associated to Service Authorization record or Contracting Provider Service Authorization record where 'All' is selected for 'Authorization Grouping Or Individual Authorizations' field (authorization by plan).
2. Note - Claim/service entry may be done via 837 Professional/837 Institutional inbound file posting, as well as 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms
3. Open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms following entry, or review in form during manual service entry (service adjudication information may also be reviewed directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
4. Navigate to 'Service Detail' section of form.
5. Select service row for and click 'Edit Selected Item'.
6. For claims/services associated to Service Authorization record or Contracting Provider Service Authorization record where 'All' is selected for 'Authorization Grouping Or Individual Authorizations' field (authorization by plan), ensure that services are adjudicated as follows:
7. Where Registry Setting 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' is enabled (and Registry Setting 'Enable Service Authorization By Plan' is enabled):
8. In case where date of service is outside of associated/selected Service Authorization record or Contracting Provider Service Authorization dates ('Begin Date of Authorization'/'End Date of Authorization'), service will be adjudicated with 'Denied' claim status
9. 'Explanation of Coverage' field will include value 'Procedure Code is not valid for this date of service' or customized EOB message if defined (via 'MSO EOB Message Customization' form)
10. Date of service check against associated/selected Service Authorization record or Contracting Provider Service Authorization dates will also incorporate 'Days Permitted Prior To Authorization Begin Date'/'Days Permitted Beyond Authorization Begin Date' settings if defined (via 'Approve/Pend/Deny Rules Definition' form)
11. In case where date of service is within associated/selected Service Authorization record or Contracting Provider Service Authorization and within associated Benefit Plan effective dates, service will be adjudicated with 'Approved' claim status (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
12. Where Registry Setting 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' is disabled (only Registry Setting 'Enable Service Authorization By Plan' enabled):
13. In case where date of service is outside of associated/selected Service Authorization record or Contracting Provider Service Authorization dates but is within associated Benefit Plan effective dates ('Date Plan Offered Effective Date'/'Date Plan Offered Expiration Date', from 'Plan Definition' form), service will be adjudicated with 'Approved' claim status
14. In case where date of service is outside of associated Benefit Plan effective dates (regardless of associated/selected Service Authorization record or Contracting Provider Service Authorization dates), service will be adjudicated with 'Denied' claim status
15. 'Explanation of Coverage' field will include value 'Date Of Service Is Beyond Plan Expiration Date'/'Date Of Service Is Prior To Plan Effective Date' or customized EOB message if defined (via 'MSO EOB Message Customization' form)

• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' must be enabled
• Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' may only be accessed/enabled by Netsmart; please contact Netsmart representative/associate for more information
• Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' must be enabled
• Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
• Avatar MSO Registry Setting 'Enable Fee Override in PM' must be set to use Parent System Service Fee Table (set to '0' or '4')
• If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined to use 'Parent System Service Fee Table' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• One or more 'Approved' status Avatar MSO services eligible for filing to parent Avatar Cal-PM system and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Close Batch' form.
2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar 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
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar Cal-PM system.
6. Open 'Client Ledger' form in parent Avatar Cal-PM system.
7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
8. Select 'Claim/Episode/All Episodes' value.
9. Select 'Ledger Type' value.
10. Click 'Process' button.
11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
12. For services originating via Avatar MSO and filed to Avatar Cal-PM parent system (where Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' is enabled):
13. Services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM Client Ledger 'Charge' value for service(s) reflects the applicable Cal-PM Service Fee Table Amount for service(s)
14. Note - Avatar Cal-PM 'Cost of Service'/'Guarantor Liability' value for service(s) originating in Avatar MSO with Other Healthcare Coverage information will reflect full Cal-PM Service Fee Table Amount, not including 'Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM
15. Note - Third Party Payment/Adjustment 'Other Healthcare Coverage' information from Avatar MSO will be stored with Cal-PM parent service to ensure correctly balanced Avatar Cal-PM outbound 837 claim information where Other Healthcare Coverage information is included in original claim/service (via SQL tables noted below)
16. Services not including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM 'Charge'/'Cost Of Service' (as well as 'Guarantor Liability') value for service(s) in Avatar Cal-PM reflects the applicable Cal-PM Service Fee Table Amount
17. Open Crystal Reports or other SQL reporting tool.
18. In Avatar Cal-PM SQL table 'SYSTEM.mso_service_cob', ensure that claim/service Third Party Payer 'Other Healthcare Coverage' filed with service via Avatar MSO is present.
19. Note - Avatar Cal-PM instance of SQL table 'SYSTEM.mso_service_cob' will on be populated with data where Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' is enabled
20. In Avatar Cal-PM SQL table 'SYSTEM.mso_claim_adjustments', ensure that claim/service Third Party Adjustment 'Other Healthcare Coverage' filed with service via Avatar MSO is present.
21. Note - Avatar Cal-PM instance of SQL table 'SYSTEM.mso_claim_adjustments' will on be populated with data where Avatar Cal-PM Registry Setting 'Enable Override MSO COB Service Charges and Line Adjustments' is enabled

1. Open Avatar MSO 'MSO EOB Message Customization' form.
2. In 'Message Type' field, select 'Miscellaneous Rules'.
3. Ensure value/entry 'Total Expected Disbursement exceeds current Account Level amount' is available in the 'Message Rule' field; select 'Total Expected Disbursement exceeds current Account Level amount'.
4. The 'Total Expected Disbursement exceeds current Account Level amount' Miscellaneous Rule Message will be used for 'Explanation of Coverage' and resulting 835 Adjustment Code information in claim/service adjudication where the Budget Tracking Account Level amount allowance claim/service adjudication rule results in denied service/reduced expected disbursement amount (in conjunction with Avatar MSO Registry Setting 'Enable Budget Tracking').
5. Ensure 'Custom Message' value and/or 'Adjustment Code'/'Remark Code' values may be specified for Message Rule; enter/update values as desired.
6. Click 'File' button to save/file MSO EOB Message Customization form entry/details.
7. On re-selecting 'Procedure Code is not valid for this date of service' in 'Message Rule' field, ensure that all previously entered/filed values for 'Custom Message' value and/or 'Adjustment Code'/'Remark Code' fields are present in form.

• Avatar MSO Registry Setting 'Enable Service Times' must be enabled
• CPT Code Definition where 'Require Service Time' is set to 'Yes' (via Avatar MSO 'CPT Code Definition' form)
• Client record(s) valid for Service Entry/Claim Processing

1. Open Avatar MSO 'Fast Service Entry' form (or 'Fast Service Entry Submission' form).
2. Enter/select value in 'Date Claims Received' and 'Close Batches' fields (if applicable).
3. Navigate to 'Fast Service Detail' section of form.
4. Click 'Add New Item' button to enter new service.
5. Enter/select client for service entry in 'Member Name or ID', field.
6. Enter/Select value in 'Funding Source' field.
7. Enter/select value in 'Provider' field.
8. Enter/select 'Date of Service' field value.
9. Enter/select 'Procedure Code' field value.
10. If 'Require Service Time' is set to 'Yes' for CPT Code entered/selected in 'Procedure Code' field, ensure that 'Service Start Time' and 'Service End Time' fields are enabled and required in form.
11. Enter/select values for all required/desired fields in form, including 'Service Start Time' and 'Service End Time' fields.
12. In case where 'Allow Service Time Overlap' is set to 'No' for CPT Code entered/selected in 'Procedure Code' field (or where 'Allow Service Time Overlap is set to 'Yes' and CPT Code entered/selected in 'Procedure Code' field is not selected for 'Overlap With Procedure Codes' field) - ensure that services for different/distinct Member IDs are not denied in Fast Service Entry form for 'Service times overlap with another service' adjudication check/reason where service times overlap for same CPT Code across two or more different/distinct Member IDs.
13. In case where 'Allow Service Time Overlap' is set to 'No' for CPT Code entered/selected in 'Procedure Code' field (or where 'Allow Service Time Overlap is set to 'Yes' and CPT Code entered/selected in 'Procedure Code' field is not selected for 'Overlap With Procedure Codes' field)- ensure that services for same/single Member ID are denied in Fast Service Entry form for 'Service times overlap with another service' adjudication check/reason where service times overlap for same CPT Code and same/single Member IDs.
14. Click 'Submit' button to file 'Fast Service Entry' form (or 'Fast Service Entry Submission' form).

• CPT Code/Service Code with Provider Fee Definition where 'Allow Duplicate Services On The Same Day?' is set to 'No' (via Avatar MSO 'Provider Fee Definition' form)
• Adjudication status for (Approve/Pend/Deny) for rule 'Duplicate Service Found' must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• Client record(s) valid for Service Entry/Claim Processing

1. Enter two or more Professional/CMS 1500 claims/services in Avatar MSO using CPT Code/Service Code where 'Allow Duplicate Services On The Same Day?' is set to 'No' for applicable Provider Fee Definition, for two or more different/distinct Member IDs.
2. Note - Professional/CMS 1500 Claim/Service entry may be done via 837 Health Care Claim Professional inbound file compilation/posting, as well as via 'Fast Service Entry' and/or 'Claim Processing (CMS 1500)' forms
3. For claims/services originating via 837 Professional inbound file posting, adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, system automatic adjudication processes and/or 'Close Batch' function).
4. During or following batch/claim/service entry - open claims/services for review via 'Claim Processing (CMS 1500)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
5. Navigate to 'Service Detail' section of form.
6. Select service row and click 'Edit Selected Item'.
7. In Avatar MSO 'Claim Processing...' forms/functions and service adjudication data - ensure that 'Duplicate service check from Provider Fee Definition' Claim Processing/Service Adjudication Approve/Pend/Deny check result for each service is determined per-Member ID (with other potentially duplicated services only being considered for single/distinct Member ID across same or different claims in system).
8. In Avatar MSO 'Claim Processing...' forms/functions and service adjudication data - ensure that duplicate services (same/single Member ID, same service date and using same CPT/Revenue Code and fee criteria as another existing 'Approved' service) are adjudicated with Claim Status value selected for 'Duplicate Service Found' Approve/Pend/Deny fields (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form).
9. 'Explanation of Coverage' field will include notice of Duplicate Service entry failed for adjudication
10. Example: 'The service was denied for the following reason: Duplicate Service Found'

• Revenue Code/Service Code with Provider Fee Definition where 'Allow Duplicate Services On The Same Day?' is set to 'No' (via Avatar MSO 'Provider Fee Definition' form)
• Adjudication status for (Approve/Pend/Deny) for rule 'Duplicate Service Found' must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
• Client record(s) valid for Service Entry/Claim Processing

1. Enter two or more Institutional/UB-04 claims/services in Avatar MSO using Revenue Code/Service Code where 'Allow Duplicate Services On The Same Day?' is set to 'No' for applicable Provider Fee Definition, for two or more different/distinct Member IDs.
2. Note - Institutional/UB-04 Claim/Service entry may be done via 837 Health Care Claim Institutional inbound file compilation/posting, as well as via 'Claim Processing (UB-04)' form
3. For claims/services originating via 837 Institutional inbound file posting, adjudicate batches/claims/services (via 'Manual Batch Adjudication' form, system automatic adjudication processes and/or 'Close Batch' function).
4. During or following batch/claim/service entry - open claims/services for review via 'Claim Processing (UB-04)' form (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
5. Navigate to 'Service Detail' section of form.
6. Select service row and click 'Edit Selected Item'.
7. In Avatar MSO 'Claim Processing...' forms/functions and service adjudication data - ensure that 'Duplicate service check from Provider Fee Definition' Claim Processing/Service Adjudication Approve/Pend/Deny check result for each service is determined per-Member ID (with other potentially duplicated services only being considered for single/distinct Member ID across same or different claims in system).
8. In Avatar MSO 'Claim Processing...' forms/functions and service adjudication data - ensure that duplicate services (same/single Member ID, same service date and using same CPT/Revenue Code and fee criteria as another existing 'Approved' service) are adjudicated with Claim Status value selected for 'Duplicate Service Found' Approve/Pend/Deny fields (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form).
9. 'Explanation of Coverage' field will include notice of Duplicate Service entry failed for adjudication
10. Example: 'The service was denied for the following reason: Duplicate Service Found'

• Avatar MSO Registry Setting 'Display Requested Units Fields' may optionally be enabled
• Avatar MSO Registry Setting 'Set Service Authorization Pre-Display' may optionally be defined with pre-display fields other than system default

1. Open one or more of the following Avatar MSO Service Authorization forms:
2. 'Service Authorization Request'
3. 'Service Authorization'
4. 'Contracting Provider Service Authorization Request'
5. 'Contracting Provider Service Authorization'
6. 'Funding Source Service Authorization'
7. Select entity for Service Authorization entry/edit (Member/Contracting Provider/Funding Source).
8. In Service Authorization form pre-display, ensure that existing Service Authorization records for selected Member/Contracting Provider/Funding Source are present and are displayed in descending order by entry date (with most recently entered record first in pre-display).
9. Ensure that clicking column heading (ex: 'Begin Date', 'Auth #') re-sorts existing records in pre-display in ascending or descending order by selected data element.
10. Select existing row and click 'Edit' for view/update, or click 'Add' button for new Service Authorization record entry.

1. Open 'Registry Settings' form.
2. Enter search value 'Enable Coverage Effective Period' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Enable Coverage Effective Period' is returned (under 'Avatar MSO -> Claims Processing' path).
4. Ensure that 'Enable Coverage Effective Period' Registry Setting may only be set to value 'N' (no/disabled) or 'Y' (yes/enabled); if any value other than 'N' or 'Y' is entered, ensure user is presented with error dialog noting 'The selected value is not valid in the current system code for the following reason: Invalid response -- must be Y or N' and the entry is disallowed.
5. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting 'Y' will add the ability to define multiple coverage effective periods with the 'CPT Code Definition' and 'Revenue Code Definition' forms. This will allow users to configure different definitions for a single CPT or Revenue Code based upon non-overlapping effective date ranges. Selecting 'Y' will do the following:

1 - Add the fields 'Coverage Period', 'Coverage Effective Date', 'Coverage Expiration Date', 'File Coverage Period', and 'Delete Coverage Period' in the 'CPT Code Definition' and 'Revenue Code Definition' forms.

2 - Add the required fields 'Coverage Period' and 'Coverage Revenue Period' the 'MSO to Parent System Integration Mapping' form for the CPT Code Mapping (Page 6) and Revenue Code Mapping (Page 7).

3 - Re-file all CPT and Revenue Code Definition mappings to map the initial coverage effective date range.

4 - Re-file all CPT and Revenue Code Definitions and create an initial coverage effective date range with an effective date of 1/1/1900.

5 - Update the CPT/Revenue Code Import to support the ability to import more than one definition for a single CPT or Revenue Code as long as the effective dates are provided and are non-overlapping.

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

• One or more client record(s) eligible for Service Authorization entry/import
• Avatar MSO 'Service Authorization - Member' Import File containing one or more valid import rows, optionally including one or more 'Edit' rows/entries

1. Open 'File Import' form in Avatar PM/Cal-PM.
2. Select File Type '[Avatar MSO] Service Authorization - Member'.
3. Click 'Process Action' button.
4. Select Avatar MSO Service Authorization - Member import file and click 'Open' button.
5. Select 'Compile/Validate File' in 'Action' field.
6. Select loaded import file and click 'Process Action' button.
7. Ensure that 'Compile/Validate File' action completes, and message 'Compiled' or '(File Name) contains one or more errors. These errors can be reviewed using 'Print Errors' action' is displayed.
8. Click 'OK' button.
9. Select 'Post File' in 'Action' field.
10. Select compiled Avatar MSO Service Authorization - Member import file and click 'Process Action' button.
11. Ensure that 'Post' action completes, and message 'Posted' and/or 'The selected file contains one or more lines with compilation errors. Only those lines without compilation errors will be posted' is displayed.
12. Open Avatar MSO 'Service Authorization' form.
13. Select Client ID for 'Service Authorization' view/edit where File Import record/row posted.
14. Select Service Authorization row/record filed via File Import in form pre-display and click 'Edit' button to open.
15. Ensure that imported/filed values are present in 'Service Authorization' form fields for new or updated file import rows/entries.

• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'Plan Definition' form.
2. Search/select existing Benefit Plan for update and click 'OK' button to open, or click 'New Plan' button to enter new Benefit Plan.
3. Enter/select values for fields in 'Plan Definition' main/first section of form as required/desired.
4. Navigate to 'Plan Coverage Definition' section of form.
5. Select existing Plan Covered Services row and click 'Edit Selected Item' button, or click 'Add New Item' button to enter new Plan Covered Services row.
6. Enter/select values for fields in 'Plan Coverage Definition' section of form as required/desired; enter/update additional Plan Covered Services row(s) as desired.
7. Click 'Submit' button to save/file 'Plan Definition' form/record.
8. Open Crystal Reports or other SQL reporting tool.
9. In Avatar MSO SQL table 'SYSTEM.plan_covered_services', ensure that entries filed via 'Plan Definition' form ('Plan Coverage Definition' section) are present in SQL table information.
10. In Avatar MSO SQL table 'SYSTEM.plan_covered_services', ensure that the field size/maximum character allowance for multi-code selection fields is 5000 characters, including the following fields:
11. 'cpt_coverage_group_code'
12. 'cpt_service_codes_code'
13. 'diag_code_for_cvg_code'
14. 'diag_code_no_cvg_code'
15. 'diag_grp_for_cvg_code'
16. 'diag_grp_no_cvg_code'
17. 'elig_reason_code'
18. 'icd10_diag_code_for_cvg_code'
19. 'icd10_diag_code_no_cvg_code'
20. 'procedure_group_code'
21. 'rev_coverage_group_code'
22. 'revenue_code_code'

• One or more Avatar MSO Contracting Provider/Performing Provider records eligible for PM/Cal-PM parent system Program/Practitioner mapping
• Crystal Reports or other SQL reporting tool

1. Open Avatar MSO 'MSO To Parent System Integration Mapping' form.
2. In first/main section of form, navigate to Avatar MSO 'Contracting Provider/Performing Provider' to Avatar PM/Cal-PM 'Staff/Program' mapping fields (third page/sub-section).
3. Enter/select value for 'Contracting Provider' and 'Performing Provider' fields.
4. Enter/select corresponding values for 'Staff' and 'Program' fields.
5. Click 'File' button to save/file 'Contracting Provider/Performing Provider' to 'Staff/Program' mapping entry; ensure user is presented with filing confirmation dialog noting 'Mapping Has Been Filed Successfully.'
6. Repeat selection/entry of additional 'Contracting Provider/Performing Provider' to 'Staff/Program' mapping entries as desired.
7. Open Crystal Reports or other SQL reporting tool.
8. In Avatar MSO SQL table 'SYSTEM.table_parentmap_per_prov', ensure that all Avatar MSO 'Contracting Provider/Performing Provider' to Avatar PM/Cal-PM 'Staff/Program' mapping entries filed via 'MSO To Parent System Integration Mapping' form ('Plan Coverage Definition' section) are present in SQL table information.

1. Open 'Registry Settings' form.
2. Enter search value 'MSO Location Field' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'MSO Location Field' is returned (under 'Avatar MSO-> Claims Processing -> Service Detail' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"The following are valid values for the behavior of the 'Location' field on the claims processing options.

0: Hide 'Location' - Default

1: Display 'Location'

2: Display and push 'Location' to Parent System.

3: Display and require 'Location'

4: Display, require and push 'Location' to Parent System.

5: Display 'Location' in all forms and require 'Location' in 'Fast Service Entry', 'Claim Processing (CMS 1500)' and 'Claim Processing with Override (CMS 1500)'.

6: Display and push 'Location' to Parent System in all forms and require 'Location' in 'Fast Service Entry', 'Claim Processing (CMS 1500)' and 'Claim Processing with Override (CMS 1500)'."

• Avatar MSO Registry Setting 'MSO Location Field' may optionally be enabled/configured (Registry Setting values '0' through '6')
• Client record(s) valid for Service Entry/Claim Processing

1. Open Avatar MSO 'Claim Processing (CMS 1500)' form (and/or 'Claim Processing With Override (CMS 1500)' form).
2. Select claims processing batch for service entry/edit.
3. Open existing claim for adjudication or create new claim for service entry/edit.
4. Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
5. Navigate to 'Service Detail' section of form.
6. Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
7. Ensure that the 'Location' field is present in 'Claim Processing (CMS 1500)' form (and required/optional for entry) according to the 'MSO Location Field' Registry Setting as follows:
8. Where 'MSO Location Field' Registry Setting value is '0' - ensure that 'Location' field is not present in form
9. Where 'MSO Location Field' Registry Setting value is '1' - ensure that 'Location' field is present in form as a non-required/optional entry field
10. Where 'MSO Location Field' Registry Setting value is '2' - ensure that 'Location' field is present in form as a non-required/optional entry field
11. Where 'MSO Location Field' Registry Setting value is '3' - ensure that 'Location' field is present in form as a required entry field
12. Where 'MSO Location Field' Registry Setting value is '4' - ensure that 'Location' field is present in form as a required entry field
13. Where 'MSO Location Field' Registry Setting value is '5' - ensure that 'Location' field is present in form as a required entry field
14. Where 'MSO Location Field' Registry Setting value is '6' - ensure that 'Location' field is present in form as a required entry field
15. Enter/select values in all other service detail fields as required/desired.
16. Click 'Add New Item' button to enter additional service(s) (or select additional existing service and click 'Edit Selected Item' button to update/adjudicate additional service(s)).
17. Click 'Submit' button to file 'Claim Processing (CMS 1500)' form (or 'Claim Processing With Override (CMS 1500)' form) and claim/service(s).

• Avatar MSO Registry Setting 'MSO Location Field' may optionally be enabled/configured (Registry Setting values '0' through '6')
• Client record(s) valid for Service Entry/Claim Processing

1. Open Avatar MSO 'Claim Processing (UB-04)' form (and/or 'Claim Processing With Override (UB-04)' form).
2. Select claims processing batch for service entry/edit.
3. Open existing claim for adjudication or create new claim for service entry/edit.
4. Set value for 'Member Name or ID' and 'Provider' in claim level section (if adding new claim/services).
5. Navigate to 'Service Detail' section of form.
6. Click 'Add New Item' button (or select existing service and click 'Edit Selected Item' button).
7. Ensure that the 'Location' field is present in 'Claim Processing (UB-04)' form (and required/optional for entry) according to the 'MSO Location Field' Registry Setting as follows:
8. Where 'MSO Location Field' Registry Setting value is '0' - ensure that 'Location' field is not present in form
9. Where 'MSO Location Field' Registry Setting value is '1' - ensure that 'Location' field is present in form as a non-required/optional entry field
10. Where 'MSO Location Field' Registry Setting value is '2' - ensure that 'Location' field is present in form as a non-required/optional entry field
11. Where 'MSO Location Field' Registry Setting value is '3' - ensure that 'Location' field is present in form as a required entry field
12. Where 'MSO Location Field' Registry Setting value is '4' - ensure that 'Location' field is present in form as a required entry field
13. Where 'MSO Location Field' Registry Setting value is '5' - ensure that 'Location' field is present in form as a non-required/optional entry field
14. Where 'MSO Location Field' Registry Setting value is '6' - ensure that 'Location' field is present in form as a non-required/optional entry field
15. Enter/select values in all other service detail fields as required/desired.
16. Click 'Add New Item' button to enter additional service(s) (or select additional existing service and click 'Edit Selected Item' button to update/adjudicate additional service(s)).
17. Click 'Submit' button to file 'Claim Processing (UB-04)' form (or 'Claim Processing With Override (UB-04)' form) and claim/service(s).

• Avatar MSO Registry Setting 'MSO Location Field' may optionally be enabled/configured (Registry Setting values '0' through '6')
• Client record(s) valid for Service Entry/Claim Processing

1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
2. Enter/select value in 'Date Claims Received' and 'Close Batches' fields (if applicable).
3. Navigate to 'Fast Service Detail' section of form.
4. Click 'Add New Item' button to enter new service.
5. Enter/select client for service entry in 'Member Name or ID', field.
6. Enter/select value in 'Funding Source', 'Provider', 'Date of Service' and 'Procedure Code' fields.
7. Ensure that the 'Location' field is present in 'Fast Service Entry' form (and required/optional for entry) according to the 'MSO Location Field' Registry Setting as follows:
8. Where 'MSO Location Field' Registry Setting value is '0' - ensure that 'Location' field is not present in form
9. Where 'MSO Location Field' Registry Setting value is '1' - ensure that 'Location' field is present in form as a non-required/optional entry field
10. Where 'MSO Location Field' Registry Setting value is '2' - ensure that 'Location' field is present in form as a non-required/optional entry field
11. Where 'MSO Location Field' Registry Setting value is '3' - ensure that 'Location' field is present in form as a required entry field
12. Where 'MSO Location Field' Registry Setting value is '4' - ensure that 'Location' field is present in form as a required entry field
13. Where 'MSO Location Field' Registry Setting value is '5' - ensure that 'Location' field is present in form as a required entry field
14. Where 'MSO Location Field' Registry Setting value is '6' - ensure that 'Location' field is present in form as a required entry field
15. Enter/select values in all other service detail fields as required/desired; repeat service entry process if desired for additional clients/services.
16. Navigate to 'Fast Service Entry Summary' main/first form section.
17. Click 'Submit Fast Service Entry' button to file services/create Avatar MSO claim processing batch(es).

• Avatar MSO Registry Setting 'Send Units to Avatar PM' must be enabled
• Avatar MSO Registry Setting 'MSO Location Field' may optionally be enabled/configured (Registry Setting values '0' through '6')
• 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
• One or more 'Approved' status services originating in Avatar MSO and eligible for filing to parent Avatar PM/Cal-PM system

1. Open Avatar MSO 'Close Batch' form.
2. 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
3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar PM/Cal-PM system.
4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
5. Click 'Submit' button to close batch/file services to parent Avatar PM/Cal-PM system.
6. In Avatar PM/Cal-PM parent system, review service information for services filed from/originating in Avatar MSO (service information may be reviewed via Avatar PM/Cal-PM 'Edit Service Information' form and/or directly via Avatar PM/Cal-PM SQL table 'SYSTEM.billing_tx_history').
7. Ensure that the 'Location' value is present in Avatar PM/Cal-PM service information for services originating in Avatar MSO according to the 'MSO Location Field' Registry Setting as follows:
8. Where 'MSO Location Field' Registry Setting value is '0' - ensure that Avatar MSO 'Location' field value is not present in Avatar PM/Cal-PM service information 'Location' field
9. Where 'MSO Location Field' Registry Setting value is '1' - ensure that Avatar MSO 'Location' field value is not present in Avatar PM/Cal-PM service information 'Location' field
10. Where 'MSO Location Field' Registry Setting value is '2' - ensure that Avatar MSO 'Location' field value is present/filed in Avatar PM/Cal-PM service information 'Location' field
11. Where 'MSO Location Field' Registry Setting value is '3' - ensure that Avatar MSO 'Location' field value is not present in Avatar PM/Cal-PM service information 'Location' field
12. Where 'MSO Location Field' Registry Setting value is '4' - ensure that Avatar MSO 'Location' field value is present/filed in Avatar PM/Cal-PM service information 'Location' field
13. Where 'MSO Location Field' Registry Setting value is '5' - ensure that Avatar MSO 'Location' field value is not present in Avatar PM/Cal-PM service information 'Location' field
14. Where 'MSO Location Field' Registry Setting value is '6' - ensure that Avatar MSO 'Location' field value is present/filed in Avatar PM/Cal-PM service information 'Location' field
15. Note - 'Location' value for Avatar PM/Cal-PM services originating in Avatar MSO may be determined/assigned by Avatar PM/Cal-PM where Avatar MSO 'Location' value is not filed under 'MSO Location Field' Registry Setting value

• One or more 'Pended' status services in Avatar MSO system

1. Open Avatar MSO 'Pended Services By Procedure Code' form/report (under 'Avatar MSO -> MSO Reporting -> Claims Processing Reports' menu path).
2. Ensure the following criteria selection fields are present in form:
3. 'Individual or All Contracting Providers'
4. 'Contracting Provider' (only enabled where 'Individual' selected in 'Individual or All Contracting Providers' field)
5. 'From Date'
6. 'Through Date'
7. Enter/select criteria for 'Pended Services By Procedure Code' report.
8. Click 'Process' button to run report/display results.
9. Ensure 'Pended Services By Procedure Code' report results are displayed in report viewer window, including the following fields/information:
10. 'Procedure Code' (CPT Code/Revenue Code)
11. 'Contracting Provider' (Name and ID)
12. 'Member Receiving Service' (Name and ID)
13. 'Date of Service'
14. 'A/P/D' (Approve/Pended/Denied claim status)
15. 'Total Fee Table Amount'
16. 'Expected Disbursement'
17. 'Member Copay'
18. 'Member Deductible'
19. 'Authorization Number'
20. 'Amount Billed'
21. Ensure that report results are limited to selected Contracting Provider' and selected 'From Date'/'Through Date' criteria; ensure that if no 'Pending' status services exist in Avatar MSO matching selected report criteria, 'No Data Found For Report' message is displayed.
22. Ensure that report results are grouped by Procedure Code (CPT Code/Revenue Code) and Contracting Provider; ensure that clicking on Procedure Code and/or Contracting Provider/display results in sub-report for only the selected data.
23. Click 'Close Report' button to close report viewer.
24. Ensure user is presented with dialog noting 'Pended Services By Procedure Code has completed. Do you wish to return to form?'; click 'Yes' button to return to 'Pended Services By Procedure Code' form or 'No' to close form.