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Avatar MSO 2024 Update 5

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Product Requirements and Recommendations

Avatar MSO required
RADplus required

Recommended Update Level

Avatar MSO 2024 Monthly Release 2024.01.00
RADplus 2024 Monthly Release 2024.01.00

Product Update Description

The following issues are resolved: 1) ProviderConnect attachments fail to move to merged member. 2) The "[UNDEFINED]GetProcCodeMapping+41^MSPPMMAPEditUtils" error produced in the 'MSO to Parent System Integration Mapping' form. 3) 277CA files generated via the 'Claim Acknowledgement (277CA) File' form is producing service information for approved services. 4) Financial Eligibility adjudication check is not recognizing coverage effective periods in the 'MSO to Parent System Integration' form. 5) Latency issues after a 'Begin Date Of Authorization' is entered in the 'Service Authorization' form.

Required Updates

None

Included Updates

None

Details
NEW0 CHANGED0 FIXED5
Fixed (5)
'Client Merge' for 'ProviderConnect File Attach' Records
An issue is resolved to ensure that ProviderConnect File Attach attachments associated to Client/Provider are moved to 'Target Client' record for non-episodic information merged via Avatar PM/Cal-PM 'Client Merge' form.
Topics
• Client Merge
 
'MSO To Parent System Integration Mapping' Form
An issue is resolved to ensure that error "[UNDEFINED]GetProcCodeMapping+41^MSPPMMAPEditUtils" does not occur in the 'MSO to Parent System Integration Mapping' form 'Mapping Delete' section in case where Contracting Provider Programs with existing Provider/Program/Service Code mapping(s) are deleted.
Topics
• MSO To Parent System Integration Mapping
 
Avatar MSO 'Claim Acknowledgement (277CA) File' Service Line Information
An issue is resolved to ensure that 277CA files generated via the Avatar MSO 'Claim Acknowledgement (277CA) File' form do not produce/include service line information for approved services. KB0076103 v0.01
Topics
• 837 Health Care Claim Institutional • 837 Health Care Claim Professional • Claims Processing
 
Avatar MSO Claim Processing Eligibility Check
An issue is resolved to ensure that Avatar MSO Claim Processing Parent System Financial Eligibility adjudication/check correctly recognizes CPT Code/Revenue Code Coverage Effective Periods where used in mappings defined via the 'MSO to Parent System Integration' form (where Avatar MSO Registry Setting 'Enable Coverage Effective Period' is enabled). KB0076093 v0.01
Topics
• Claims Processing • CPT Code Definition • MSO To Parent System Integration Mapping • Registry Settings • Revenue Code Definition
 
Avatar MSO 'Service Authorization' Form
An issue is resolved to prevent form latency issues after a 'Begin Date Of Authorization' is entered/selected in the Avatar MSO 'Service Authorization' form.
Topics
• Service Authorizations
 
Acceptance Tests
AV-94527 Summary | Details
'Client Merge' for 'ProviderConnect File Attach' Records
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • ProviderConnect File Attach
Scenario 1: 'Client Merge' - Verification of 'ProviderConnect File Attach' Information
Specific Setup:
  • 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
Steps
  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.
Topics
• Client Merge
AV-95498 Summary | Details
'MSO To Parent System Integration Mapping' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Contracting Provider Registration
  • MSO to Parent System Integration Mapping
Scenario 1: 'MSO To Parent System Integration Mapping' - Verification of Mapping Deletion
Specific Setup:
  • 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)
Steps
  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.
Topics
• MSO To Parent System Integration Mapping
AV-95592 Summary | Details
Avatar MSO 'Claim Acknowledgement (277CA) File' Service Line Information
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Institutional
  • 837 Health Care Claim Professional
  • Claim Acknowledgement (277CA) File
  • Claim Acknowledgement (277CA) File - Dump File Report
  • Claim Acknowledgement (277CA) File - Report
Scenario 1: 'Claim Acknowledgement (277CA) File' - Verification of Claim Acknowledgement File Service Line Information
Specific Setup:
  • 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
Steps
  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~
Topics
• 837 Health Care Claim Institutional • 837 Health Care Claim Professional • Claims Processing
AV-95771 Summary | Details
Avatar MSO Claim Processing Eligibility Check
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • 837 Health Care Claim Institutional
  • 837 Health Care Claim Professional
  • Claim Processing (CMS 1500)
  • Claim Processing (UB-04)
  • CPT Code Definition (MSO)
  • Fast Service Entry
  • Financial Eligibility
  • Funding Source/Guarantor Mapping
  • MSO to Parent System Integration Mapping
  • Registry Settings (PM)
  • Revenue Code Definition (MSO)
Scenario 1: Avatar MSO Claim Processing - Financial Eligibility Check, Verification of 'Enable Coverage Effective Period' Registry Setting
Specific Setup:
  • 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
Steps
  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.
Topics
• Claims Processing • CPT Code Definition • MSO To Parent System Integration Mapping • Registry Settings • Revenue Code Definition
AV-95775 Summary | Details
Avatar MSO 'Service Authorization' Form
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Service Authorization
Scenario 1: 'Service Authorization' - Form Verification
Specific Setup:
  • Client record eligible for Service Authorization entry/update
Steps
  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.
Topics
• Service Authorizations