Avatar MSO 2024 Update 9

1. Open 'Registry Settings' form.
2. Enter search value 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Set Batch File Naming Convention' is returned (under 'Avatar MSO-> Care Management -> Service Authorization' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting "Y" will enforce the system during claim processing to validate that the Date of Service falls within the effective date range of the reported or associated Authorization when that Service or Contracting Provider Authorization has been authorized by the Plan Definition.

Selecting "N" will enforce the system during claim processing to validate that the date of Services falls within the effective date range of the Plan Definition selected in the reported or associated Service or Contracting Provider Authorization.

To enable this registry setting, the setting 'Enable Service Authorization by Plan' must be set to "Y"."

Note - Explanation text/'Registry Setting Details' field contents for Avatar MSO Registry Setting 'Enable Service Authorization By Plan' has also been updated as follows:

"Selecting 'Y' will add "All" as a choice for the field 'Authorization Grouping Or Individual Authorizations' on both the 'Service Authorization' and 'Contracting Provider Service Authorization' forms. When "All" is selected for an authorization, the authorization will cover all services defined within the plan. When this is set to 'Y', during claim processing, the system will validate the Date of Service against the effective dates of the authorized Plan Definition. To validate the Date of Service against the effective dates within the reported Authorization, the registry setting "Enforce Adjudication for Authorization Dates When Authorizing by Plan" must also be enabled.

Selecting 'N' will remove "All" as a choice for the field 'Authorization Grouping Or Individual Authorizations' on both the 'Service Authorization' and 'Contracting Provider Service Authorization' forms."

1. Open Avatar MSO 'MSO EOB Message Customization' form.
2. In 'Message Type' field, select 'Miscellaneous Rules'.
3. Ensure value/entry 'Procedure Code is not valid for this date of service' is available in the 'Message Rule' field; select 'Procedure Code is not valid for this date of service'.
4. The 'Procedure Code is not valid for this date of service' Miscellaneous Rule Message will be used for 'Explanation of Coverage' and resulting 837/835 adjustment code information in claim/service adjudication where check on authorization begin/end dates is failed when validating Service Authorization and Contracting Provider Service Authorizations by Plan (in conjunction with Avatar MSO Registry Settings 'Enable Service Authorization by Plan' and 'Enforce Adjudication for Authorization Dates When Authorizing by Plan').
5. Ensure 'Custom Message' value and/or 'Adjustment Code'/'Remark Code' values may be specified for Message Rule; enter/update values as desired.
6. Click 'File' button to save/file MSO EOB Message Customization form entry/details.
7. 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.

• Avatar MSO Registry Setting 'Enable Service Authorization By Plan' must be enabled
• Avatar MSO Registry Setting 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' must be enabled
• Client with eligible Service Authorization record and/or Contracting Provider Service Authorization record valid for Service Entry/Claim Processing, where 'All' is selected for 'Authorization Grouping Or Individual Authorizations' field

1. Enter one or more claims/services in Avatar MSO, associated to Service Authorization record or Contracting Provider Service Authorization record where 'All' is selected for 'Authorization Grouping Or Individual Authorizations' field (authorization by plan).
2. Note - Claim/service entry may be done via 837 Professional/837 Institutional inbound file posting, as well as 'Fast Service Entry', 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms
3. Open claims/services for review via 'Claim Processing (CMS 1500)' and/or 'Claim Processing (UB-04)' forms following entry, or review in form during manual service entry (service adjudication information may also be reviewed directly via Avatar MSO SQL table 'SYSTEM.batch_clm_svc_detail').
4. Navigate to 'Service Detail' section of form.
5. Select service row for and click 'Edit Selected Item'.
6. For claims/services associated to Service Authorization record or Contracting Provider Service Authorization record where 'All' is selected for 'Authorization Grouping Or Individual Authorizations' field (authorization by plan), ensure that services are adjudicated as follows:
7. Where Registry Setting 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' is enabled (and Registry Setting 'Enable Service Authorization By Plan' is enabled):
8. In case where date of service is outside of associated/selected Service Authorization record or Contracting Provider Service Authorization dates ('Begin Date of Authorization'/'End Date of Authorization'), service will be adjudicated with 'Denied' claim status
9. 'Explanation of Coverage' field will include value 'Procedure Code is not valid for this date of service' or customized EOB message if defined (via 'MSO EOB Message Customization' form)
10. Date of service check against associated/selected Service Authorization record or Contracting Provider Service Authorization dates will also incorporate 'Days Permitted Prior To Authorization Begin Date'/'Days Permitted Beyond Authorization Begin Date' settings if defined (via 'Approve/Pend/Deny Rules Definition' form)
11. In case where date of service is within associated/selected Service Authorization record or Contracting Provider Service Authorization and within associated Benefit Plan effective dates, service will be adjudicated with 'Approved' claim status (Subject to all other defined/applicable Approve/Pend/Deny Rules and Claim Processing settings)
12. Where Registry Setting 'Enforce Adjudication for Authorization Dates When Authorizing by Plan' is disabled (only Registry Setting 'Enable Service Authorization By Plan' enabled):
13. In case where date of service is outside of associated/selected Service Authorization record or Contracting Provider Service Authorization dates but is within associated Benefit Plan effective dates ('Date Plan Offered Effective Date'/'Date Plan Offered Expiration Date', from 'Plan Definition' form), service will be adjudicated with 'Approved' claim status
14. In case where date of service is outside of associated Benefit Plan effective dates (regardless of associated/selected Service Authorization record or Contracting Provider Service Authorization dates), service will be adjudicated with 'Denied' claim status
15. 'Explanation of Coverage' field will include value 'Date Of Service Is Beyond Plan Expiration Date'/'Date Of Service Is Prior To Plan Effective Date' or customized EOB message if defined (via 'MSO EOB Message Customization' form)