'MSO EOB Message Customization' Messages
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- MSO EOB Message Customization
Scenario 1: 'MSO EOB Message Customization' - Form Verification
Steps
- Open Avatar MSO 'MSO EOB Message Customization' form.
- In 'Message Type' field, select 'Miscellaneous Rules'.
- 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'.
- 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').
- Ensure 'Custom Message' value and/or 'Adjustment Code'/'Remark Code' values may be specified for Message Rule; enter/update values as desired.
- Click 'File' button to save/file MSO EOB Message Customization form entry/details.
- 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.
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Topics
• Claims Processing
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Avatar MSO 'Fast Service Entry' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- CPT Code Definition (MSO)
- Fast Service Entry
- Fast Service Entry Submission
- Registry Settings (PM)
Scenario 1: 'Fast Service Entry' - Verification Of Service Time Fields/Service Time Overlap Adjudication
Specific Setup:
- 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
Steps
- Open Avatar MSO 'Fast Service Entry' form (or 'Fast Service Entry Submission' form).
- Enter/select value in 'Date Claims Received' and 'Close Batches' fields (if applicable).
- Navigate to 'Fast Service Detail' section of form.
- Click 'Add New Item' button to enter new service.
- Enter/select client for service entry in 'Member Name or ID', field.
- Enter/Select value in 'Funding Source' field.
- Enter/select value in 'Provider' field.
- Enter/select 'Date of Service' field value.
- Enter/select 'Procedure Code' field value.
- 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.
- Enter/select values for all required/desired fields in form, including 'Service Start Time' and 'Service End Time' fields.
- 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.
- 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.
- Click 'Submit' button to file 'Fast Service Entry' form (or 'Fast Service Entry Submission' form).
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Topics
• Claims Processing
• CPT Code Definition
• Registry Settings
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Avatar MSO Claim Processing Duplicate Service Check
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- 837 Health Care Claim Professional
- Approve/Pend/Deny Rules Definition
- Claim Processing (CMS 1500)
- Manual Batch Adjudication
- Provider Fee Definition
- 837 Health Care Claim Institutional
- Claim Processing (UB-04)
- Close Batch
Scenario 1: Claim Processing (CMS 1500) - Verification of Approve/Pend/Deny Rule Definition for Duplicate Services
Specific Setup:
- 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
Steps
- 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.
- 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
- 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).
- 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').
- Navigate to 'Service Detail' section of form.
- Select service row and click 'Edit Selected Item'.
- 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).
- 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).
- 'Explanation of Coverage' field will include notice of Duplicate Service entry failed for adjudication
- Example: 'The service was denied for the following reason: Duplicate Service Found'
Scenario 2: Claim Processing (UB-04) - Verification of Approve/Pend/Deny Rule Definition for Duplicate Services
Specific Setup:
- 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
Steps
- 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.
- 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
- 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).
- 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').
- Navigate to 'Service Detail' section of form.
- Select service row and click 'Edit Selected Item'.
- 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).
- 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).
- 'Explanation of Coverage' field will include notice of Duplicate Service entry failed for adjudication
- Example: 'The service was denied for the following reason: Duplicate Service Found'
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Topics
• Claims Processing
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