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Avatar MSO 2024 Update 2

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Product Requirements and Recommendations

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Product Update Description

The following modifications are made: 1) The 'Approve/Pend/Deny Rules Definition' form has been updated to allow one funding source to have multiple definitions spanning over a specified date range. 2) The issue is resolved where the popup message "Procedure Not On Fee Schedule." produces incorrectly after entering a procedure code in the Fast Service Entry forms if fees are defined for specific contracting provider programs. 3) The issue is resolved where if the 'Max Services Per Claim' field in the 'Approve/Pend/Deny Rules Definition' form is set to 1 service per claim, the 'Fast Service Entry' form would deny all services when there is more than one row entered in for different clients. 4) An issue is resolved where MSO services with third party payments would not come to PM with expected disbursement as the service charge.

Required Updates

None

Included Updates

None

Details
NEW2 CHANGED0 FIXED3
New (2)
Avatar MSO 'Approve/Pend/Deny Rules Definition' form
The Avatar MSO 'Approve/Pend/Deny Rules Definition' form is updated to allow A/P/D Rules for a Funding Source to be defined for date range periods.
Approve/Pend/Deny Rules may be defined for single or multiple/distinct date range Rule Coverage Periods for a single Funding Source, allowing Avatar MSO Claim Processing/Service Adjudication forms and functions to evaluate rules/adjudication status based on service date. In addition, Avatar MSO SQL table 'SYSTEM.apd_rule_def' is added for storage of date range coverage period Approve/Pend/Deny Rules Definition information.
On installation of Avatar MSO 2024 Update 2, a default Rule Coverage Period entry with 'Start Date' of '1/1/1990' and no 'End Date' value will be defined for each/all Funding Sources based on Approve/Pend/Deny Rules Definition information existing prior to update.
Value Added: Allows Approve/Pend/Deny Rule Coverage Periods to be defined by date range
Topics
• Approve/Pend/Deny Rules Definition
 
Avatar MSO 'Approve/Pend/Deny Rules Definition' Claim Processing
Avatar MSO Claim Processing functions are updated to support Approve/Pend/Deny Rules/adjudication status based on service date.

Avatar MSO Claim Processing/Service Adjudication forms and functions are updated to support Approve/Pend/Deny Rules defined by Rule Coverage Period(s) for Funding Source compared to 'Date of Service', including the following forms/functions:

  • 'Claim Processing (CMS 1500)'
  • 'Claim Processing (UB-04)'
  • 'Fast Service Entry'/'Fast Service Entry Submission'
  • '837 Health Care Claim Professional'
  • '837 Health Care Claim Institutional'
  • 'Manual Batch Adjudication'
Value Added: Adds support for Approve/Pend/Deny Rules by Rule Coverage Period for Claim Processing/Service Adjudication
Topics
• 837 Health Care Claim Institutional • 837 Health Care Claim Professional • Approve/Pend/Deny Rules Definition • Claims Processing
 
Fixed (3)
Avatar MSO 'Fast Service Entry' form
An issue is resolved in the 'Fast Service Entry' form (and 'Fast Service Entry Submission' form) to ensure that services entered for distinct/multiple clients are not incorrectly denied under the 'Number of Services Per Claim Allowed' Approve/Pend/Deny Rule.
Topics
• Approve/Pend/Deny Rules Definition • Claims Processing
 
Avatar MSO 'Fast Service Entry' form
An issue is resolved in the 'Fast Service Entry' form (and 'Fast Service Entry Submission' form) to ensure that the 'Procedure Not On Fee Schedule' error/alert dialog is not incorrectly displayed on CPT Service Code selection in case where Provider Fee for selected code is defined using Contracting Provider Program. KB0075325 v0.01
Topics
• Claims Processing
 
Avatar MSO to Avatar Cal-PM Parent System Service Filing
An issue is resolved to ensure that Avatar MSO services including Third Party Payment/Adjustment information are filed/pushed to Avatar Cal-PM with expected disbursement as the service charge (to ensure correctly balanced Avatar Cal-PM outbound 837 claim information where Other Healthcare Coverage information is included in original claim/service).
Topics
• Claims Processing • MSO To Parent System Integration Mapping • Registry Settings
 
Acceptance Tests
AV-86854 Summary | Details
Avatar MSO 'Fast Service Entry' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Approve/Pend/Deny Rules Definition
  • Fast Service Entry
Scenario 1: 'Fast Service Entry' - Verification of 'Number of Services Per Claim Allowed' Adjudication Rule
Specific Setup:
  • Field 'Number of Services Per Claim Allowed' in Avatar MSO 'Approve/Pend/Deny Rules Definition' form must be defined
  • Field 'Number of Services Per Claim Allowed Exceeded' in Avatar MSO 'Approve/Pend/Deny Rules Definition' form must be defined
  • Two or more client records eligible for claim/service entry
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
  2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
  6. Enter/select values in all other service detail fields in form as required/desired.
  7. Click 'Add New Item' button.
  8. Enter/select service entry information values, using different/distinct Client ID in the 'Member Name or ID' field.
  9. Select value for 'Authorization Number' field.
  10. Ensure that in case where 'Member Name or ID' differs between service rows entered in 'Fast Service Entry' form, services not exceeding the 'Number of Services Per Claim Allowed' setting are not incorrectly denied with adjudication reason 'Number of services per claim allowed exceeded' in case where services for different/distinct clients do not exceed limit.
  11. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
  12. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
Topics
• Approve/Pend/Deny Rules Definition • Claims Processing
AV-88346 Summary | Details
Avatar MSO 'Approve/Pend/Deny Rules Definition' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Approve/Pend/Deny Rules Definition
Scenario 1: 'Approve/Pend/Deny Rules Definition' - Form Verification
Specific Setup:
  • Crystal Reports or other SQL reporting tool
Steps
  1. Open Avatar MSO 'Approve/Pend/Deny Rules Definition' form.
  2. Select Funding Source for Approve/Pend/Deny Rules Definition entry/edit.
  3. Ensure the following fields are present in the 'Approve/Pend/Deny Rules Definition' form:
  4. 'Rule Coverage Period'
  5. Dropdown selection field including existing A/P/D Rule Coverage Periods as well as 'Create New' selection
  6. On installation of Avatar MSO 2024 Update 2, a default A/P/D Rule Coverage Period entry with 'Start Date' of '1/1/1990' and no 'End Date' value is defined for each/all Funding Sources based on Approve/Pend/Deny Rules Definition information existing prior to update (to allow for Claim Processing/Service Adjudication under same A/P/D Rule conditions as defined prior to update for all services).
  7. 'Start Date'
  8. Start Date for A/P/D Rule Coverage Period (required); services with 'Date of Service' on or after this date will be adjudicated according to A/P/D rules defined for this Rule Coverage Period
  9. 'End Date'
  10. End Date for A/P/D Rule Coverage Period; services (not required); if defined, services with 'Date of Service' on or before this date will be adjudicated according to A/P/D rules defined for this Rule Coverage Period
  11. If 'End Date' is not defined, A/P/D Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  12. Select existing A/P/D Rule Coverage Period for edit/review, or select 'Create New' for new A/P/D Rule Coverage Period entry.
  13. Enter value for 'Start Date' field (and 'End Date' if desired).
  14. Enter/select values for all Approve/Pend/Deny Rule fields/settings as required/desired.
  15. Click 'Submit' button to file Approve/Pend/Deny Rules Definition' form/Rule Coverage Period information.
  16. In case where Rule Coverage Period 'Start Date'/'End Date' values overlap another Rule Coverage Period defined for the same Funding Source - Ensure that user is presented with an error dialog noting 'Date ranges are overlapping, please adjust dates appropriately', submission/filing is canceled and user is returned to form to correct overlapping dates
  17. In case where Rule Coverage Period 'End Date' value is prior to 'Start Date' value - Ensure that user is presented with an error dialog noting 'End Date needs to be the same day or later than Start Date', submission/filing is canceled and user is returned to form to correct invalid dates
  18. Re-open 'Approve/Pend/Deny Rules Definition' form.
  19. In 'Rule Coverage Period', ensure all previously entered/filed Rule Coverage Periods are available for selection.
  20. Select existing A/P/D Rule Coverage Period for edit/review.
  21. Ensure that previously entered/selected values for all Approve/Pend/Deny Rule fields are present in form for selected A/P/D Rule Coverage Period.
  22. Open Crystal Reports or other SQL reporting tool.
  23. In Avatar MSO SQL table 'SYSTEM.apd_rule_def', ensure that Approve/Pend/Deny Rule field values/information are present for all A/P/D Rule Coverage Periods entered/filed in Avatar MSO.
  24. Note - Avatar MSO SQL table 'SYSTEM.table_app_pen_den_rules' is no longer used for storage of 'Approve/Pend/Deny Rules Definition' form information and will not reflect/include any information filed after Avatar MSO 2024 Update 2 installation; all updated/added 'Approve/Pend/Deny Rules Definition' form information will be filed/stored in Avatar MSO SQL table 'SYSTEM.apd_rule_def'
Topics
• Approve/Pend/Deny Rules Definition
AV-88347 Summary | Details
Avatar MSO 'Approve/Pend/Deny Rules Definition' Claim Processing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Approve/Pend/Deny Rules Definition
  • Claim Processing (CMS 1500)
  • Manual Batch Adjudication
  • Claim Processing (UB-04)
  • 837 Health Care Claim Professional
  • 837 Health Care Claim Institutional
  • Fast Service Entry
  • Fast Service Entry Submission
Scenario 1: 'Claim Processing (HCFA 1500)' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Enter one or more claims/services in Avatar MSO using Funding Source where one or more Approve/Pend/Deny Rule Coverage Period(s) are defined in system.
  2. Note - Claim/Service entry may be done via 'Fast Service Entry'/'Claim Processing (CMS 1500)' forms and/or '837 Health Care Claim Professional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
  3. During or following batch/claim/service entry - open claims/services for review via 'Claim Processing (CMS 1500)' (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
  4. Navigate to 'Service Detail' section of form.
  5. Select service row and click 'Edit Selected Item'.
  6. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  7. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  8. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  9. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  10. Examples:
  11. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
  12. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
  13. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  14. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
Scenario 2: 'Claim Processing (UB-04)' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Enter one or more claims/services in Avatar MSO using Funding Source where one or more Approve/Pend/Deny Rule Coverage Period(s) are defined in system.
  2. Note - Claim/Service entry may be done via 'Claim Processing (UB-04)' form and/or '837 Health Care Claim Institutional' file compilation/posting, as well as Avatar MSO Automated inbound 837 inbound file processing functionality
  3. During or following batch/claim/service entry - open claims/services for review via 'Claim Processing (UB-04)' (or review directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
  4. Navigate to 'Service Detail' section of form.
  5. Select service row and click 'Edit Selected Item'.
  6. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  7. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  8. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  9. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  10. Examples:
  11. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
  12. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
  13. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  14. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
Scenario 3: '837 Health Care Claim Professional' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • 837 Health Care Claim Professional file with one or more valid claims
Steps
  1. Open Avatar MSO '837 Health Care Claim Professional' form.
  2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
  3. Select 'Load File' in the 'Options' field.
  4. Enter file path for inbound 837 Professional format file and click 'Process' button.
  5. Select 'Compile File' in the 'Options' field, and select loaded 837 Professional file.
  6. Click 'Process' button.
  7. In 837 Professional Compile Report - ensure that one or more claims/services are successfully compiled.
  8. Select 'Post File' in the 'Options' field.
  9. Select compiled 837 Professional format file and click 'Process' button.
  10. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  11. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  12. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  13. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  14. Examples:
  15. 'The service was approved with the following notices: Maximum Number Of Units Of Procedure Code Per Day Exhausted. Invalid Measurement Code for Procedure Code. Location's Place of Service Is Invalid For Procedure Code. Limited by total charge'
  16. 'The service was denied for the following reasons: Specified Duration is not valid for Procedure Code. Invalid Measurement Code for Procedure Code. The service also has the following Approval notices: Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Claim Submitted with a Date Range'
  17. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  18. In 837 Professional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
  19. Note - Select claim processing/service adjudication Approve/Pend/Deny rules/functionality occurs within the system batch/claim adjudication process (and not in 837 inbound file compilation/posting). Avatar MSO Claim Processing batch(es) must be adjudicated following 837 file posting in order for services to reflect all Approve/Pend/Deny rules/adjudication 'Explanation of Coverage', 'Expected Disbursement' and 'Approved Units' values
Scenario 4: '837 Health Care Claim Institutional' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • 837 Health Care Claim Institutional file with one or more valid claims
Steps
  1. Open Avatar MSO '837 Health Care Claim Institutional' form.
  2. Note - Acceptance testing may also be confirmed via Avatar MSO Automated inbound 837 inbound file processing functionality
  3. Select 'Load File' in the 'Options' field.
  4. Enter file path for inbound 837 Institutional format file and click 'Process' button.
  5. Select 'Compile File' in the 'Options' field, and select loaded 837 Institutional file.
  6. Click 'Process' button.
  7. In 837 Institutional Compile Report - ensure that one or more claims/services are successfully compiled.
  8. Select 'Post File' in the 'Options' field.
  9. Select compiled 837 Institutional format file and click 'Process' button.
  10. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  11. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  12. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  13. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  14. Examples:
  15. 'The service was approved with the following notices: Maximum Number Of Units Of Procedure Code Per Day Exhausted. Invalid Measurement Code for Procedure Code. Location's Place of Service Is Invalid For Procedure Code. Limited by total charge'
  16. 'The service was denied for the following reasons: Specified Duration is not valid for Procedure Code. Invalid Measurement Code for Procedure Code. The service also has the following Approval notices: Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Claim Submitted with a Date Range'
  17. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  18. In 837 Institutional Compile/Post Report and resulting Avatar MSO claim/service data - Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
  19. Note - Select claim processing/service adjudication Approve/Pend/Deny rules/functionality occurs within the system batch/claim adjudication process (and not in 837 inbound file compilation/posting). Avatar MSO Claim Processing batch(es) must be adjudicated following 837 file posting in order for services to reflect all Approve/Pend/Deny rules/adjudication 'Explanation of Coverage', 'Expected Disbursement' and 'Approved Units' values
Scenario 5: 'Fast Service Entry' - Verification of Approve/Pend/Deny Rule Definition By Coverage Period/Date
Specific Setup:
  • Approve/Pend/Deny Rules for one or more Rule Coverage Period(s) must be defined (via Avatar MSO 'Approve/Pend/Deny Rules Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
  2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', 'Procedure Code', 'Total Charge', 'Service Units' and 'Authorization Number' fields.
  6. Enter/select values in all other service detail fields in form as required/desired.
  7. Ensure that 'Claim Status' field (Approved/Denied/Pending) is populated with value determined by Avatar MSO Approve/Pend/Deny service adjudication rules/status settings, using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (compared to 'Start Date' and 'End Date' for defined A/P/D Rule Coverage Period(s)).
  8. Services with 'Date of Service' on or after A/P/D Rule Coverage Period 'Start Date' and on or before 'End Date' (where defined) will be adjudicated according to A/P/D rules and status' defined for applicable Rule Coverage Period
  9. If 'End Date' is not defined for A/P/D Rule Coverage Period, Rule Coverage Period will be considered applicable to all services where 'Date of Service' is on or after 'Start Date'
  10. Ensure that 'Explanation Of Coverage' field is populated with service adjudication information from applicable A/P/D Rule Coverage Period as pertains to claim/service status.
  11. Examples:
  12. 'The service was approved with the following notices: Duration Per Unit For Procedure Code Is Incorrect. Specified Treating Provider Type On Authorization Not Claimed.'
  13. 'The service was denied for the following reasons: Diagnosis For Authorization Is Not Specified On Claim. Service Exceeded Allowed Number Of Days Prior to Date Of Claim. Specified Treating Facility Member On Authorization Not Claimed.'
  14. Ensure that 'Expected Disbursement' and 'Approved Units' fields are populated with value determined by Avatar MSO claim/service adjudication rules and requirements in conjunction with 'Claim Status'.
  15. Ensure that all Approve/Pend/Deny Rule conditions where status is defined/selected for the applicable A/P/D Rule Coverage Period are evaluated for each service entered/all services in claim.
  16. On editing one or more service detail field values related to claim adjudication/status (including 'Date of Service') - ensure that 'Claim Status'/'Explanation of Coverage' information is re-processed using A/P/D Rule Coverage Period Rules applicable to 'Date of Service' (and claim/service adjudication status and information updated accordingly).
  17. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
  18. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
Topics
• 837 Health Care Claim Institutional • 837 Health Care Claim Professional • Approve/Pend/Deny Rules Definition • Claims Processing
AV-93020 Summary | Details
Avatar MSO 'Fast Service Entry' form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Fast Service Entry
Scenario 1: 'Fast Service Entry' - Form Verification
Specific Setup:
  • Avatar MSO Registry Setting 'Enable Contracting Provider Program' must be enabled
  • CPT Code where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included (via Avatar 'Provider Fee Definition' form)
  • Client record eligible for claim/service entry
Steps
  1. Open Avatar MSO 'Fast Service Entry' form (and/or 'Fast Service Entry Submission' form).
  2. Select/edit values for 'Close Batches' and 'Date Claims Received' fields if desired/allowed.
  3. Navigate to 'Fast Service Detail' section of form.
  4. Click 'Add New Item' button to enter new service.
  5. Enter/select service entry information values in 'Member Name or ID', 'Funding Source', 'Provider', 'Date of Service', and 'Contracting Provider Program' fields.
  6. Select value in 'Procedure Code' field, selecting CPT Code where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included.
  7. Ensure that in case where Provider Fee Definition exists with 'Performing Provider Program' criteria defined/included for the selected CPT Code/Procedure Code, user is not incorrectly presented with dialog noting 'Procedure Not On Fee Schedule'.
  8. Enter/select values in 'Total Charge', 'Service Units' and 'Authorization Number' fields, as well all other service detail fields as required/desired.
  9. Click 'Add New Item' button to enter additional service(s) as desired; when all desired services have been entered in 'Fast Service Detail' section of form, navigate to 'Fast Service Entry Summary' section of form.
  10. Click 'Submit Fast Service Entry' form to file service(s) and create Avatar MSO claims processing batch(es).
Topics
• Claims Processing
AV-94718 Summary | Details
Avatar MSO to Avatar Cal-PM Parent System Service Filing
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Client Ledger
  • Close Batch
  • MSO to Parent System Integration Mapping
  • Registry Settings (PM)
Scenario 1: 'Close Batch' - Avatar MSO to Cal-PM Parent System Service Filing, Verification of Service Filing With Fee Override Enabled for Services with Other Healthcare Coverage Information
Specific Setup:
  • Avatar Cal-PM Parent System is required for Acceptance Testing with Registry Setting 'Support MSO Other Healthcare Coverage' enabled
  • Avatar MSO Registry Setting 'Add Support For The Input Of Third Party Payer Amounts' must be enabled
  • Avatar MSO Registry Setting 'Enable Fee Override in PM' must be enabled (set to '1','2', '3' or '4')
  • If Avatar MSO Registry Setting 'Enable Fee Override in PM' is set to '4', 'Fee Override in PM' date/override type entry for service date(s) must be defined (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section, 'Enable Fee Override in PM' sub-section)
  • 'File Services On Closing Of Batch Or Creation of EOB?' must be set to 'Yes' (via Avatar MSO 'MSO to Parent System Integration Mapping' form 'Service Filing' section)
  • CPT Code/Revenue Code must be selected/included for Fee Override in filing to parent system (via Avatar 'Provider Fee Definition' form)
  • One or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system and including Third Party Payment/Adjustment 'Other Healthcare Coverage' information
Steps
  1. Open Avatar MSO 'Close Batch' form.
  2. Note - Acceptance Testing may also be confirmed on service filing to parent Avatar PM system via Avatar MSO 'Create EOB' or 'Other EOB Information' entry/filing where 'Inhibit Service Filing' restrictions are defined via 'MSO to Parent System Integration Mapping' form 'Service Filing' section
  3. Select Avatar MSO Claims Processing batch containing one or more 'Approved' status services eligible for filing to parent Avatar Cal-PM system.
  4. Set 'Close Batch' field to 'Yes' (and click 'OK' button to close warning message dialog).
  5. Click 'Submit' button to close batch/file services to parent Avatar PM system.
  6. Open 'Client Ledger' form in parent Avatar Cal-PM system.
  7. Select 'Client ID' value for client where services are present in Avatar MSO closed status Claims Processing batch.
  8. Select 'Claim/Episode/All Episodes' value.
  9. Select 'Ledger Type' value.
  10. Click 'Process' button.
  11. In Client Ledger data, ensure that 'Approved' status services originating in Avatar MSO are present in Avatar Cal-PM system following 'Close Batch' filing (where services are valid for filing to parent system).
  12. For services originating via Avatar MSO and filed to Avatar Cal-PM parent system (where Avatar Cal-PM Registry Setting 'Support MSO Other Healthcare Coverage' and Avatar MSO Registry Setting 'Enable Fee Override in PM' are enabled):
  13. Services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM Client Ledger 'Charge' value for service(s) reflects the 'Allowed Amount' value (or 'Expected Disbursement' value if differing) from Avatar MSO Other Healthcare Coverage information for service(s)
  14. Note - In case where PM Service Fee Table Amount is selected for parent system service filing, services including Third Party Payment/Adjustment 'Other Healthcare Coverage' information will use Avatar MSO Allowed Amount/Expected Disbursement service value for Cal-PM parent service 'Cost of Service'/'Guarantor Liability' (to ensure correctly balanced Avatar Cal-PM outbound 837 claim information where Other Healthcare Coverage information is included in original claim/service)
  15. Note - Avatar Cal-PM 'Cost of Service'/'Guarantor Liability' value for service(s) originating in Avatar MSO with Other Healthcare Coverage information will reflect Client Ledger Charge/Allowed Amount/Expected Disbursement value not including Other Healthcare Coverage' Third Party Payment amounts for service filed to Avatar Cal-PM
  16. Services not including Third Party Payment/Adjustment 'Other Healthcare Coverage' information - Ensure that Avatar Cal-PM 'Charge'/'Cost Of Service' (as well as 'Guarantor Liability') value for service(s) in Avatar Cal-PM reflects the selected/applicable Avatar MSO Fee Override Type (Expected Disbursement/Fee Table Amount/Total Charge), or PM Service Fee Table Amount where override not selected
Topics
• Claims Processing • MSO To Parent System Integration Mapping • Registry Settings
Table Changes
Table Column Change
apd_rule_def FACILITY ADD
apd_rule_def funding_source ADD
apd_rule_def claim_level_adjustment ADD
apd_rule_def claim_submitted_with_date_range ADD
apd_rule_def claim_submitter_id_processed ADD
apd_rule_def days_prior_to_claim ADD
apd_rule_def days_prior_to_claim_allowance ADD
apd_rule_def days_prior_to_replacement_claim ADD
apd_rule_def days_prior_to_replacement_claim_allowance ADD
apd_rule_def fiscal_year_span ADD
apd_rule_def granular_duplicated_params ADD
apd_rule_def granular_duplicated_service ADD
apd_rule_def granular_zero_fee_service ADD
apd_rule_def ignore_num_services_per_claim_manual ADD
apd_rule_def individual_level_annual_admission ADD
apd_rule_def individual_level_annual_dollars ADD
apd_rule_def individual_level_annual_units ADD
apd_rule_def individual_level_annual_visits ADD
apd_rule_def individual_level_daily_dollars ADD
apd_rule_def individual_level_lifetime_admission ADD
apd_rule_def individual_level_lifetime_dollars ADD
apd_rule_def individual_level_lifetime_units ADD
apd_rule_def individual_level_lifetime_visits ADD
apd_rule_def invalid_contr_prov_prog ADD
apd_rule_def invalid_diagnosis_on_authorization ADD
apd_rule_def invalid_duration_for_procedure_code ADD
apd_rule_def invalid_duration_per_unit_for_procedure_code ADD
apd_rule_def invalid_measurement_code ADD
apd_rule_def invalid_place_of_service_for_procedure_code ADD
apd_rule_def invalid_treat_doc ADD
apd_rule_def invalid_treat_doc_type ADD
apd_rule_def maximum_procedure_code_units_per_day ADD
apd_rule_def member_ineligible ADD
apd_rule_def no_function_begin_date_allowance ADD
apd_rule_def no_function_end_date_allowance ADD
apd_rule_def no_function_pay_lower_total_charge ADD
apd_rule_def no_admitting_diagnosis ADD
apd_rule_def num_services_per_claim_allowed ADD
apd_rule_def num_services_per_claim_exceeded ADD
apd_rule_def overall_account_dollars_exceeded ADD
apd_rule_def overall_account_dollars_not_exceeded ADD
apd_rule_def overall_annual_admission ADD
apd_rule_def overall_annual_dollars ADD
apd_rule_def overall_annual_units ADD
apd_rule_def overall_annual_visits ADD
apd_rule_def overall_daily_dollars ADD
apd_rule_def overall_lifetime_admission ADD
apd_rule_def overall_lifetime_dollars ADD
apd_rule_def overall_lifetime_units ADD
apd_rule_def overall_lifetime_visits ADD
apd_rule_def pay_total_charge_if_greater_than_fee_table_and_third_party_coverage_identified ADD
apd_rule_def plan_effective_date ADD
apd_rule_def plan_end_date ADD
apd_rule_def start_date ADD
apd_rule_def end_date ADD
apd_rule_def third_party_and_svc_not_fully_covered_by_auth ADD
apd_rule_def third_party_coverage ADD
apd_rule_def third_party_guarantor_exists ADD
apd_rule_def third_party_payment_amounts_exceed_total_third_party_payment_amount ADD
apd_rule_def unknown_third_party_coverage ADD