Approve/Pend/Deny Rule Definition - 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 Institutional
- 837 Health Care Claim Professional
- Admission (Outpatient)
- Approve/Pend/Deny Rules Definition
- Authorization Selection - No Authorizations On File Error
- Batch Creation
- Batch Creation - Assign ID
- Claim Processing (UB-04)
- Contracting Provider Registration
- CPT Code Definition (PM)
- Crystal Report Viewer
- Diagnosis
- Financial Eligibility
- Funding Source Registration
- Member Specific Information
- Plan Definition
- Provider Fee Definition
- Service Authorization
- Claim Processing (CMS 1500)
- Manual Batch Adjudication
- Authorization Listing
- Revenue Code Definition (PM)
Scenario 1: 837 Health Care Claim Professional' - Verification of Approve/Pend/Deny Rule Definition for same day duplicate services
Specific Setup:
- Registry Setting:
- Set the 'Avatar MSO->Claims Processing->Service Detail->->->Enable Check for Duplicated Services' to 'N'.
- Guarantors/Payors:
- An existing guarantor is identified to be used. Note the guarantor code/name.
- 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 for compilation and posting. Note the location of the file.
Steps
- Open the '837 Health Care Claim Professional' form.
- Load an inbound 837 file including duplicate services on the same date successfully matched to clients/episodes in Avatar MSO.
- Compile loaded 837 file.
- Verify the 837 file does not compile successfully.
- Launch the report.
- Verify that the first claim/service is approved and second service on the same day is denied.
- Review the 'Explanation Of Benefit' for the second claim.
- Verify the 'Explanation Of Coverage' contains the message 'The service was denied for the following reason: Duplicate Service Found'.
- Close the report.
- Close the form.
Scenario 2: Claim Processing (CMS 1500) - Verification of Approve/Pend/Deny Rule Definition for the duplicate service
Specific Setup:
- Registry Setting:
- Set the 'Avatar MSO->Claims Processing->Service Detail->->->Enable Check for Duplicated Services' to 'N'.
- Guarantors/Payors:
- An existing guarantor is identified to be used. Note the guarantor code/name.
- 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.
Steps
- Open Avatar 'Claim Processing (CSM-1500)' form.
- Select claims processing batch for service entry/edit.
- Open existing claim or create new claim for the service entry/edit.
- Set value for 'Member Name or ID' and 'Provider' in claim level section of form (and any other required/desired fields).
- Navigate to 'Service Detail' section of the form.
- Click [Add New Item].
- Enter/select values for 'Date of Service', 'Procedure Code', 'Total Charge' and 'Service Units' fields.
- Enter/select value for 'Authorization Number' field (or click 'Display Valid Authorizations' button and select valid Service Authorization row).
- Verify the 'Claim Status' for the service entry is set to 'Approved'.
- Verify the 'Total Fee Table Amount' field is populated correctly with the total charge entered.
- Verify the 'Total Disbursement' field is populated correctly with the total charge entered.
- Verify the 'Approved Units' field is populated correctly with the service units entered.
- Click [Add New Item].
- Enter/select same values for 'Date of Service', 'Procedure Code', 'Total Charge' and 'Service Units' fields.
- Enter/select same value for 'Authorization Number' field (or click 'Display Valid Authorizations' button and select valid Service Authorization row).
- Verify the 'Claim Status' for the service entry is set to 'Denied'.
- Verify the 'Explanation Of Coverage' contains the message 'The service was denied for the following reason: Duplicate Service Found'.
- Click [Submit].
- Open the 'Manual Batch Adjudication' form.
- Select desired batch number from the 'Select Batches' drop down.
- Click [Process].
- Verify the batch adjudicated successfully.
- Close the form.
- Open Avatar 'Claim Processing (CMS-1500)' form.
- Select the same claims processing batch for service entry/edit.
- Open existing claim for the service entry/edit.
- Set value for 'Member Name or ID' and 'Provider' in claim level section of form (and any other required/desired fields).
- Navigate to 'Service Detail' section of the form.
- Verify the 'Claim Status' column correctly displays the 'Approved' status for the first service and 'Denied' status for the second service.
- Close the form.
Scenario 3: Claim Processing (UB-04) - Verification of Approve/Pend/Deny Rule Definition for duplicate service
Specific Setup:
- Registry Setting:
- Set the 'Avatar MSO->Claims Processing->Service Detail->->->Enable Check for Duplicated Services' to 'N'.
- Guarantors/Payors:
- An existing guarantor is identified to be used. Note the guarantor code/name.
- 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.
- Revenue Code Definition:
- Identify an existing revenue code or create a new revenue code. Note the revenue 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 revenue 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.
Steps
- Open Avatar 'Claim Processing (UB-04)' form.
- Select claims processing batch for service entry/edit.
- Open existing claim or create new claim for service entry/edit.
- Set value for 'Member Name or ID' and 'Provider' in claim level section of form (and any other required/desired fields).
- Navigate to 'Service Detail' section of the form.
- Click [Add New Item].
- Enter/select values for 'Date of Service', 'Revenue Code', 'Total Charge' and 'Service Units' fields.
- Enter/select value for 'Authorization Number' field (or click 'Display Valid Authorizations' button and select valid Service Authorization row).
- Verify the 'Claim Status' for the service entry is set to 'Approved'.
- Verify the 'Total Fee Table Amount' field is populated correctly with the total charge entered.
- Verify the 'Total Disbursement' field is populated correctly with the total charge entered.
- Verify the 'Approved Units' field is populated correctly with the service units entered.
- Click [Add New Item].
- Enter/select same values for 'Date of Service', 'Revenue Code', 'Total Charge' and 'Service Units' fields.
- Enter/select same value for 'Authorization Number' field (or click 'Display Valid Authorizations' button and select valid Service Authorization row).
- Verify the 'Claim Status' for the service entry is set to 'Denied'.
- Verify the 'Explanation Of Coverage' contains the message 'The service was denied for the following reason: Duplicate Service Found'.
- Click [Submit].
- Open the 'Manual Batch Adjudication' form.
- Select desired batch number from the 'Select Batches' drop down.
- Click [Process].
- Verify the batch adjudicated successfully.
- Close the form.
- Open Avatar 'Claim Processing (UB-04)' form.
- Select the same claims processing batch for service entry/edit.
- Open existing claim for the service entry/edit.
- Set value for 'Member Name or ID' and 'Provider' in claim level section of form (and any other required/desired fields).
- Navigate to 'Service Detail' section of the form.
- Verify the 'Claim Status' column correctly displays the 'Approved' status for the first service and 'Denied' status for the second service.
- Close the form.
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Topics
• 837 Health Care Claim Professional
• 837 Professional
• Claims Processing
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