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Avatar PM 2022 Update 12

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Avatar PM 2021 Update 83.1

Product Update Form Description

A Three-day billing issue is resolved where claims are being split when qualifying for three day billing error message.

Included Updates

None

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Details
NEW0 CHANGED0 FIXED1
Fixed (1)
Quick Billing - 3 Day Billing Rule
Resolves an issue to ensure that services in the first episode cannot be billed due to the 3-Day Billing Rule when the readmission occurs within 3 days from the discharge date of the first episode and the through date within 3 days from the discharged from the second episode. KB0067984 v0.01
Topics
• NX • Quick Billing
 
Acceptance Tests
AV-76290 Summary | Details
Quick Billing - 3 Day Billing Rule
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission
  • Client Ledger
  • Diagnosis
  • Discharge
  • Dynamic Form - Admission - Client
  • Dynamic Form - Pre-Display Confirmation
  • Dynamic Form Compile Complete
  • Financial Eligibility
  • Guarantors/Payors
  • Quick Billing
  • Quick Billing Rule Definition
  • App Dashboard
  • Ok - Cancel Dialog
  • Crystal Report Viewer
  • Dynamic Form - Edit Service Fee Definition
  • Service Codes
  • Dynamic Form - Plan
Scenario 1: 3 Day Billing Rule - Single client episode - Processing 837 Institutional with a through date greater than 3 days after discharge date
Specific Setup:
  • Guarantors/Payors:
  • A guarantor is created or edited with the field 'Does This Guarantor Get Billed Under 3-Day Billing Rule?' set to "Yes".
  • Admission:
  • The client is admitted to the inpatient program or an existing inpatient client is identified.
  • Diagnosis:
  • An admission diagnosis record is created for the client.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the client.
  • Client Charge Input:
  • 5 Services are rendered to the client in the first episode. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Discharge:
  • The client is discharged after 5 days from the first episode. Please note the discharge date.
  • Client Ledger:
  • Verify the charges are correctly distributed to the desired guarantor, and they are in 'Open' status.
  • Quick Billing Rule Definition:
  • The quick Billing Rules are created to include service(s) distributed to the client.
Steps
  1. Open the ‘Quick Billing’ form.
  2. Set the field ‘Add New Or Edit Existing Quick Billing Batch’ to "Add New".
  3. Set the field ‘First Date Of Service To Include’ to first date of the service.
  4. Set the field ‘Last Date Of Service To Include’ to the date that is greater than 3 days after discharge date.
  5. Set the field ‘Billing Rule To Execute’ to desired rule created in setup section.
  6. Set the field ‘Quick Billing Tasks To Execute’ to "Create Batch, Close Charges, Generate Bills".
  7. Set the field ‘Date Of Claim’ to desired date.
  8. Submit the form.
  9. Verify the 'Compile Complete' message. The message also displays the quick billing batch number and Interim Billing Batch number.
  10. Click [OK].
  11. Open the 'Client Ledger' form.
  12. Select desired client.
  13. Select "All Episode" from the 'Claim/Episode/All Episode' field.
  14. Select "Simple" from the 'Ledger Type' field.
  15. Select desired date in the 'From Date' and 'To Date' fields to include the service date range for the client.
  16. Click [Process].
  17. Verify the services are claimed and the claim number is generated.
Scenario 2: 3 Day Billing Rule - Single client episode - Processing 837 Institutional with a through date within 3 days after discharge date
Specific Setup:
  • Guarantors/Payors:
  • A guarantor is created or edited with the field 'Does This Guarantor Get Billed Under 3-Day Billing Rule?' set to "Yes".
  • Admission:
  • The client is admitted to the inpatient program or an existing inpatient client is identified.
  • Diagnosis:
  • An admission diagnosis record is created for the client.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the client.
  • Client Charge Input:
  • 5 Services are rendered to the client in the first episode. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Discharge:
  • The client is discharged after 5 days from the first episode. Please note the discharge date.
  • Client Ledger:
  • Verify the charges are correctly distributed to the desired guarantor, and they are in 'Open' status.
  • Quick Billing Rule Definition:
  • The quick Billing Rules are created to include service(s) distributed to the client.
Steps
  1. Open the ‘Quick Billing’ form.
  2. Set the field ‘Add New Or Edit Existing Quick Billing Batch’ to "Add New".
  3. Set the field ‘First Date Of Service To Include’ to first date of the service.
  4. Set the ‘Last Date Of Service To Include’ to the date that is less than or equal to 3 days after discharge date.
  5. Set the field ‘Billing Rule To Execute’ to desired rule created in setup section.
  6. Set the field ‘Quick Billing Tasks To Execute’ to "Create Batch, Close Charges, Generate Bills".
  7. Set the field ‘Date Of Claim’ to desired date.
  8. Submit the form.
  9. Verify the 'Compile Complete Errors Found' message. The message also displays the quick billing batch number and Interim Billing Batch number.
  10. Click [OK].
  11. Select 'Edit Existing' in the ‘Add New Or Edit Existing Quick Billing Batch’ field.
  12. Select desired file from the 'File' dropdown list.
  13. Click [Print 837 Report].
  14. Click the 'Required Data Missing: Subscriber and/or Patient Name Data' link.
  15. Verify the 'Episode cannot be billed due to 3 day billing rule' error message is displayed for the desired episode.
  16. Close the report.
  17. Close the form.
Scenario 3: 3 Day Billing Rule - Running an 837 Institutional bill - Readmission occurs within 3 days after discharge - there is at least a 60 day service period between first and last episodes
Specific Setup:
  • Registry Setting:
  • The 'Enable New Quick Billing Format' registry setting is set to 'Y'.
  • Guarantors/Payors:
  • A new guarantor is created or an existing guarantor is updated. Note the GurantorID and guarantor name.
  • Make sure the field 'Does This Guarantor Get Billed Under 3-Day Billing Rule?' is set to "Yes".
  • Make sure the 'Does This Guarantor Get Billed Under PPS Rules?' is set to "Yes".
  • Admission:
  • The client is admitted to the inpatient program or an existing inpatient client is identified. Note the admission date, admission program and client id for further testing.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the client.
  • An existing service code is identified to be used for inpatient client and make sure to have fee definition for the service.
  • Recurring Client Charge Input:
  • 2-3 Services are rendered to the client in the first episode. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Diagnosis:
  • An admission diagnosis is added for the client.
  • Discharge:
  • The client is discharged after last date of the service. Please note the discharge date.
  • Diagnosis:
  • A Discharge diagnosis is added for the client.
  • Re-Admission - Second episode:
  • A new admission is created for the client within 3 days of when the last episode was discharged. Please note the date of admission and admission program.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the second episode of the client.
  • Diagnosis:
  • An admission diagnosis is added for the client for the second episode.
  • Recurring Client Charge Input:
  • Charges are added to the client that exceeds a 60-day period from the first admission date. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Discharge:
  • The client is discharged from the second episode on the next day after last service in the second episode. Please note the discharge date.
  • Diagnosis:
  • A Discharge diagnosis for the second episode is added for the client.
  • Client Ledger:
  • Verify the charges are correctly distributed to the desired guarantor, and they are in 'Open' status.
  • Quick Billing Rule Definition:
  • The quick Billing Rule definition is created to include service(s), client and guarantor for both the episode.
Steps
  1. Open the ‘Quick Billing’ form.
  2. Set the field ‘Add New Or Edit Existing Quick Billing Batch’ to "Add New".
  3. Set the field ‘First Date Of Service To Include’ to first date of the service.
  4. Set the field ‘Last Date Of Service To Include’ to a date that is greater than 3 days after discharge date.
  5. Set the field ‘Billing Rule To Execute’ to desired rule created in setup section.
  6. Set the field ‘Quick Billing Tasks To Execute’ to "Create Batch, Close Charges, Generate Bills".
  7. Set the field ‘Date Of Claim’ to desired date.
  8. Submit the form.
  9. Verify the 'Compile Complete' message contains error found. The message also displays the quick billing batch number and Interim Billing Batch number.
  10. Click [OK].
  11. Validate the 'Form Return' dialog occurs.
  12. Click [Yes].
  13. Select 'Edit Existing' radio button in the 'Add New Or Edit Existing Quick Billing Batch' field.
  14. Select the file that recently compiled from the 'File' drop down.
  15. Click [Print 837 Report].
  16. Click on the 'Required Data Missing: Subscriber and/or Patient Name Data' link.
  17. Verify the error message for the episode that occurs within 3 days from the discharge of the last episode.
  18. Open the 'Client Ledger' form.
  19. Select desired client.
  20. Select "All Episode" from the 'Claim/Episode/All Episode' field.
  21. Select "Simple" from the 'Ledger Type' field.
  22. Select desired date in the 'From Date' and 'To Date' fields to include the service date range for the client.
  23. Click [Process].
  24. Verify the services are 'Unbilled' in status.
Scenario 4: 3 Day Billing Rule - Readmission occurs post 3 days from the discharge of first episode - Processing an 837 Institutional with a through date <= 3 days from the discharge date
Specific Setup:
  • Registry Setting:
  • The 'Enable New Quick Billing Format' registry setting is set to 'Y'.
  • Guarantors/Payors:
  • A new guarantor is created, or an existing guarantor is updated. Note the GurantorID and guarantor name.
  • The field 'Does This Guarantor Get Billed Under 3-Day Billing Rule?' is set to "Yes".
  • The field 'Does This Guarantor Get Billed Under PPS Rules?' is set to "Yes".
  • Admission:
  • The client is admitted to an inpatient program or an existing inpatient client is identified. Note the admission date, admission program and client id for further testing.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the client.
  • An existing service code, with a fee definition, is identified to be used for inpatient client.
  • Recurring Client Charge Input:
  • 2-3 Services are rendered to the client in the first episode. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Diagnosis:
  • An admission diagnosis is added for the client.
  • Discharge:
  • The client is discharged after last date of the service. Please note the discharge date.
  • Diagnosis:
  • A Discharge diagnosis is added for the client.
  • Re-Admission - Second episode:
  • A new admission is created for the client after 3 days of when the previous episode was discharged. Please note the date of admission and admission program.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the second episode of the client.
  • Diagnosis:
  • An admission diagnosis is added for the client for the second episode.
  • Recurring Client Charge Input:
  • 2-3 Services are rendered to the client in the first episode. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Discharge:
  • The client is discharged from the second episode on the day after last service in the second episode. Please note the discharge date.
  • Diagnosis:
  • A Discharge diagnosis for the second episode is added for the client.
  • Client Ledger:
  • Verify the charges are correctly distributed to the desired guarantor, and they are in 'Open' status.
  • Quick Billing Rule Definition:
  • A quick Billing Rule definition is created to include service(s), client and guarantor for both the episode.
Steps
  1. Open the ‘Quick Billing’ form.
  2. Set the field ‘Add New Or Edit Existing Quick Billing Batch’ to "Add New".
  3. Set the field ‘First Date Of Service To Include’ to the first date of service.
  4. Set the field ‘Last Date Of Service To Include’ to a date that is within 3 days after last discharge date.
  5. Set the field ‘Billing Rule To Execute’ to rule created in setup section.
  6. Select the 'Create Batch', 'Close Charges', 'Generate Bills', 'Create Claims' options in the ‘Quick Billing Tasks To Execute’ field.
  7. Set the field ‘Date Of Claim’ to desired date.
  8. Submit the form.
  9. Verify the 'Compile Complete' message. The message also displays the quick billing batch number and Interim Billing Batch number.
  10. Click [OK].
  11. Open the 'Client Ledger' form.
  12. Select desired client.
  13. Select "All Episode" from the 'Claim/Episode/All Episode' field.
  14. Select "Simple" from the 'Ledger Type' field.
  15. Select desired date in the 'From Date' and 'To Date' fields to include the service date range for the client.
  16. Click [Process].
  17. Verify the services are claimed and the claim number is generated.
Scenario 5: 3 Day Billing Rule - Readmission occurs within 3 days from the discharge of first episode - Processing an 837 Institutional with a through date <= 3 days from the discharge date
Specific Setup:
  • Registry Setting:
  • The 'Enable New Quick Billing Format' registry setting is set to 'Y'.
  • Guarantors/Payors:
  • A new guarantor is created, or an existing guarantor is updated. Note the GurantorID and guarantor name.
  • The field 'Does This Guarantor Get Billed Under 3-Day Billing Rule?' is set to "Yes".
  • The field 'Does This Guarantor Get Billed Under PPS Rules?' is set to "Yes".
  • Admission:
  • The client is admitted to an inpatient program or an existing inpatient client is identified. Note the admission date, admission program and client id for further testing.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the client.
  • An existing service code, with a fee definition, is identified to be used for inpatient client.
  • Recurring Client Charge Input:
  • 2-3 Services are rendered to the client in the first episode. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Diagnosis:
  • An admission diagnosis is added for the client.
  • Discharge:
  • The client is discharged after last date of the service. Please note the discharge date.
  • Diagnosis:
  • A Discharge diagnosis is added for the client.
  • Re-Admission - Second episode:
  • A new admission is created for the client within 3 days of when the previous episode was discharged. Please note the date of admission and admission program.
  • Financial Eligibility:
  • The guarantor identified above is assigned to the second episode of the client.
  • Diagnosis:
  • An admission diagnosis is added for the client for the second episode.
  • Recurring Client Charge Input:
  • 2-3 Services are rendered to the client in the first episode. Be sure to use service codes that are covered by the benefit plan (insurance charge category).
  • Discharge:
  • The client is discharged from the second episode on the day after last service in the second episode. Please note the discharge date.
  • Diagnosis:
  • A Discharge diagnosis for the second episode is added for the client.
  • Client Ledger:
  • Verify the charges are correctly distributed to the desired guarantor, and they are in 'Open' status.
  • Quick Billing Rule Definition:
  • A quick Billing Rule definition is created to include service(s), client and guarantor for both the episode.
Steps
  1. Open the ‘Quick Billing’ form.
  2. Set the field ‘Add New Or Edit Existing Quick Billing Batch’ to "Add New".
  3. Set the field ‘First Date Of Service To Include’ to the first date of service.
  4. Set the field ‘Last Date Of Service To Include’ to a date that is within 3 days after last discharge date.
  5. Set the field ‘Billing Rule To Execute’ to rule created in setup section.
  6. Select the 'Create Batch', 'Close Charges', 'Generate Bills', 'Create Claims' options in the ‘Quick Billing Tasks To Execute’ field.
  7. Set the field ‘Date Of Claim’ to desired date.
  8. Submit the form.
  9. Verify the 'Compile Complete' message. The message also displays the quick billing batch number and Interim Billing Batch number.
  10. Click [OK].
  11. Open the 'Client Ledger' form.
  12. Select desired client.
  13. Select "All Episode" from the 'Claim/Episode/All Episode' field.
  14. Select "Simple" from the 'Ledger Type' field.
  15. Select desired date in the 'From Date' and 'To Date' fields to include the service date range for the client.
  16. Click [Process].
  17. Verify the services are not claimed. The first episode receives the three day billing error and does not claim. The second episode receives the missing diagnosis error and will not get picked up in the batch.
Topics
• NX • Quick Billing

 

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