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Avatar MSO 2024 Update 26

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Product Requirements and Recommendations

Avatar MSO required
RADplus required

Recommended Update Level

Avatar MSO 2024 Monthly Release 2024.01.02
RADplus 2024 Monthly Release 2024.01.02

Product Update Description

Avatar MSO is updated to support the '2310D' and '2420D' segments on 837 Professional files.

Required Updates

None

Included Updates

None

Details
NEW1 CHANGED0 FIXED0
New (1)
SYSTEM.billing_837p_claim_data and SYSTEM.billing_837p_service_data - Field validation
SQL tables SYSTEM.billing_837p_claim_data and SYSTEM.billing_837p_service_data are enhanced to add new fields to store information from the 2310D/2420D NM1 element from the 837 Health Claim Professional file.
Users can find additional fields within the SYSTEM.billing_837p_claim_data and SYSTEM.billing_837p_service_data SQL tables. These fields are specifically designed to capture and store data from the 2310D/2420D NM1 If an inbound MSO claim has supervising practitioner information included in the 2310D and/or 2420D segment of the 837 Health Claim Professional file.
Value Added: Enhance data accuracy and integrity for billing processes with new field validations, directly benefiting client’s operational efficiency. This new feature is relevant as it improves the overall user experience and ensures the precision of billing data.
Topics
• 837 Health Care Claim Professional • 837 Professional • Database Management
 
Acceptance Tests
AV-97580 Summary | Details
SYSTEM.billing_837p_claim_data and SYSTEM.billing_837p_service_data - Field validation
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Professional
  • Admission (Outpatient)
  • Contracting Provider Registration
  • CPT Code Definition (MSO)
  • CPT Code Definition (PM)
  • Diagnosis
  • Financial Eligibility
  • Funding Source Registration
  • Member Specific Information
  • Performing Provider Registration
  • Plan Definition
  • Provider Fee Definition
  • Service Authorization
Scenario 1: 837 Health Care Claim Professional - Supervising practitioner information included in 2310D loop – Validating ‘SYSTEM.billing_837p_claim_data’ and an outbound 837 Professional bill
Specific Setup:
  • Admission:
  • An existing outpatient client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • An active diagnosis record is created for the client. Note the diagnosis date and diagnosis code.
  • CPT Code Definition:
  • Identify an existing CPT code or create a new CPT code. Note the CPT code/description.
  • Funding Source Registration:
  • Identify an existing funding source or create a new funding source. Note the funding source / registration date.
  • Plan Definition:
  • Identify an existing plan definition for the funding source identified or create a new plan definition. Note the plan id, name, and effective date.
  • Provider Fee Definition:
  • New fee definition is created for the member and provider for the identified CPT code. Note the effective date.
  • Member Specific Information:
  • Member and funding source specific information are added in this form.
  • Service Authorization:
  • An approved authorization is created for the client identified above. Note the authorization number for later use.
  • Batch Creation:
  • New batch is created for the service entry. Note the batch number for later use.
  • 837 Professional format inbound file for compilation and posting which contains NM1*DQ segment at the claim level. Note the name/location path of the file.
Steps
  1. Open the '837 Health Care Claim Professional' form.
  2. Select "Load File" from the 'Options' field.
  3. Set the File Path\Name text field to the desired path where an inbound 837 professional file is located that contains an 2420D-NM1-DQ segment and matched to the clients/episodes in Avatar MSO. Note the name of the file.
  4. Click [Process].
  5. Verify the crystal report lunched successfully.
  6. Verify that the report displays all the data from the file.
  7. Click [x].
  8. Select "Compile File" from the 'Options' field.
  9. Set the 'Date Claims Received' to desired date.
  10. Select the recently loaded file from the 'Select File' dropdown list.
  11. Click [Process].
  12. Verify the file compiles successfully and the crystal report lunched successfully.
  13. Verify that all the claims/services approved and included correctly in the report.
  14. Close the report.
  15. Select "Post File" from the 'Options' field.
  16. Set the 'Date Claims Received' to desired date.
  17. Select the recently compiled file from the 'Select File' dropdown list.
  18. Click [Process].
  19. Verify the file posts successfully and the crystal report lunched successfully.
  20. Verify that all the claims/services approved and included correctly in the report.
  21. Close the report.
  22. Close the form.
  23. Open the 'Crystal Report' or any other SQL Data Viewer.
  24. Locate to the MSO namespace of the system.
  25. Query 'Select * from SYSTEM.billing_837p_claim_data'.
  26. Validate the 'sup_prov_code_qualif' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  27. Validate the 'sup_prov_first_name' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  28. Validate the 'sup_prov_identifier' cell is equal to the value added for this item in the 837 Health Care Claim Professional file.
  29. Validate the 'sup_prov_last_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  30. Validate the 'sup_prov_mid_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  31. Close The Application.
Scenario 2: 837 Health Care Claim Professional - Supervising practitioner information included in 2420D loop – Validating ‘SYSTEM.billing_837p_service_data’ (Cal-PM /PM side)
Specific Setup:
  • Admission:
  • An existing outpatient client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Diagnosis:
  • An active diagnosis record is created for the client. Note the diagnosis date and diagnosis code.
  • CPT Code Definition:
  • Identify an existing CPT code or create a new CPT code. Note the CPT code/description.
  • Funding Source Registration:
  • Identify an existing funding source or create a new funding source. Note the funding source / registration date.
  • Plan Definition:
  • Identify an existing plan definition for the funding source identified or create a new plan definition. Note the plan id, name, and effective date.
  • Provider Fee Definition:
  • New fee definition is created for the member and provider for the identified CPT code. Note the effective date.
  • Member Specific Information:
  • Member and funding source specific information are added in this form.
  • Approve/Pend/Deny Rules Definition:
  • A definition is created for an existing funding source and the 'Duplicate Service Found' is set to 'Deny'.
  • Member ID' is checked in the 'Duplicate Service' parameters.
  • Service Authorization:
  • An approved authorization is created for the client identified above. Note the authorization number for later use.
  • Batch Creation:
  • New batch is created for the service entry. Note the batch number for later use.
  • 837 Professional format inbound file is created that have supervising practitioner information included in 2310D and/or 2420D segments. That contains an 2310D-NM1-DQ and 2420D-NM1-DQ segments and matched to the clients/episodes in Avatar MSO. Note the name/location path of the file.
Steps
  1. Open the '837 Health Care Claim Professional' form.
  2. Select "Load File" from the 'Options' field.
  3. Set the 'File Path\Name' text field to the desired path where an inbound 837 professional file is located that contains an 2420D-NM1-DQ segment and matched to the clients/episodes in Avatar MSO. Note the name of the file.
  4. Click [Process].
  5. Verify the crystal report lunched successfully.
  6. Verify that the report displays all the data from the file.
  7. Click [x].
  8. Select "Compile File" from the 'Options' field.
  9. Set the 'Date Claims Received' to desired date.
  10. Select the recently loaded file from the 'Select File' dropdown list.
  11. Click [Process].
  12. Verify the file compiles successfully and the crystal report lunched successfully.
  13. Verify that all the claims/services approved and included correctly in the report.
  14. Close the report.
  15. Select "Post File" from the 'Options' field.
  16. Set the 'Date Claims Received' to desired date.
  17. Select the recently compiled file from the 'Select File' dropdown list.
  18. Click [Process].
  19. Verify the file posts successfully and the crystal report lunched successfully.
  20. Verify that all the claims/services approved and included correctly in the report.
  21. Close the report.
  22. Close the form.
  23. Open the 'Crystal Report' or any other SQL Data Viewer.
  24. Locate to the MSO namespace of the system.
  25. Query 'Select * from SYSTEM.billing_837p_service_data'.
  26. Validate the 'sup_prov_code_qualif' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  27. Validate the 'sup_prov_first_name' cell contains correct value added for this item in the 837 Health Care Claim Professional file.
  28. Validate the 'sup_prov_identifier' cell is equal to the value added for this item in the 837 Health Care Claim Professional file.
  29. Validate the 'sup_prov_last_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  30. Validate the 'sup_prov_mid_name' cell is equal the value added for this item in the 837 Health Care Claim Professional file.
  31. Close The Application.
Topics
• 837 Health Care Claim Professional • 837 Professional • Database Management