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Avatar PM 2022 Update 121

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Product Requirements / Recommendations

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Product Update Form Description

The following is included: 1) The 'Bill Only When Full Denial Received For Medicare A No-Pay Guarantor' field is added to 'Guarantors/Payors' (837). 2) The 'SYSTEM.medicare_a_hold' table is added to track services that are on hold due to the above new field. 3) The 'Medicare A Service Hold Management' form is added. 4) The 837 Institutional is modified to skip services that are on hold due to the above new field. 5) The 'Unbilled Services Compile Definition and Export' is modified to include services that are unbilled due to the above new field. 6) The '835 Health Care Claim Payment/Advice' is modified to remove holds from the 'SYSTEM.medicare_a_hold' table once all services are denied by the Medicare A No-Pay guarantor.

Included Updates

3, 9, 13, 15, 18, 19, 20, 21, 25, 26, 34, 37, 41, 48, 51, 55, 58, 59, 61, 62, 67, 73, 75, 77, 78, 84, 87, 88, 90, 91, 94, 95, 97, 99, 100, 103, 107, 108, 109, 110, 114, 117, 118, 120

Required Updates

None

Details
NEW1 CHANGED0 FIXED0
New (1)
837 Institutional – Medicare A - No Pay Claims
The 837 Institutional functionality is updated for Medicare No-Pay Claims.
The 'Bill Only When Full Denial Received For Medicare A No-Pay Guarantor' field is added to 'Guarantors/Payors' (837).
The 837 Institutional is modified to skip services that are on hold due to the above new field.
The 'Unbilled Services Compile Definition and Export' is modified to include services that are unbilled due to the above new field.
The 'SYSTEM.medicare_a_hold' table is added to track services that are on hold due to the above new field.
The 'Medicare A Service Hold Management' form is added.
The '835 Health Care Claim Payment/Advice' is modified to remove holds from the 'SYSTEM.medicare_a_hold' table once all services are denied by the Medicare A No-Pay guarantor.
Value Added: Allows users to determine billing options by guarantor.
Topics
• 837 Institutional • Guarantor/Payors • NX • Web Services
 
Acceptance Tests
AV-80764 Summary | Details
837 Institutional – Medicare A - No Pay Claims
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Guarantors/Payors
  • Registry Settings (PM)
  • 835 Health Care Claim Payment/Advice (PM)
  • Admission
  • Claim Adjustment Group/Reason Code Definition
  • Client Ledger
  • Create Interim Billing Batch File
  • Diagnosis
  • Electronic Billing
  • Financial Eligibility
  • Practitioner Numbers By Guarantor And Program
  • Program Maintenance
  • Service Codes
  • SQL Query
  • System Task Scheduler
  • Unbilled Services Compile Definition and Export
  • User Definition
  • Client Charge Input
  • Delete Service
  • Medicare A Service Hold Management
Scenario 1: 837 Institutional - Bill Only When Full Denial Received For Medicare A No-Pay Guarantor
Specific Setup:
  • User Definition:
  • Tester has been given access to the 'Medicare A Service Hold Management' form.
  • Tester has been given access to the 'SYSTEM.medicare_a_hold' table.
  • Guarantors/Payor:
  • Guarantor 1:
  • Select a Medicare A guarantor: Note the 'Guarantor Code', 'Guarantor Name' and 'Financial Class'.
  • Select 'Yes' in 'Generate No-Pay ##0 Claims'.
  • Select desired value in 'Include No-Pay ##0 Claims In Separate 837 File'.
  • Select desired values in 'Type of Service to Include in No-Pay ##0 Claims'.
  • Guarantor 2:
  • Select an existing guarantor to be the secondary guarantor in Financial Eligibility. Note the 'Guarantor Code', 'Guarantor Name' and 'Financial Class'.
  • Select desired value in 'Generate No-Pay ##0 Claims'.
  • In the 837 section, select 'Yes' in 'Bill Only When Full Denial Received For Medicare A No-Pay Guarantor'. Note: Services will be placed on hold during liability distribution until a full denial is received for the Medicare A guarantor in an 835.
  • Client:
  • Admission: An inpatient client is admitted. Note the client's id/name, program, and date of admission.
  • Financial Eligibility:
  • Guarantor 1 is the primary guarantor. Customize the guarantor plan to allow a portion of the service charge to distribute to Guarantor 2.
  • Guarantor 2 is the secondary guarantor, and the guarantor plan allows payment of the portion of the service charge distributed to Guarantor 2.
  • Client Charge Input: Room & Board charges are rendered to the client for a minimum of one day.
  • Client Ledger: Validate that the charges distributed to both guarantors.
  • Close the charges.
  • Electronic Billing: Create 837 Institutional claims for Guarantor 1.
  • Save the dump file to use to create a mockup 835 file that fully denies the claims. Save the file for further testing.
  • Create a query of the ‘SYSTEM.medicare_a_hold’ table specific to the client.
  • Validate that there is one row for each service and: ‘GUARANTOR_ID’ = Guarantor 2 guarantor code; ‘PATID’ = the client’s ID; and ‘medicare_a_id’ = Guarantor 1 guarantor code.
Steps
  1. Open ‘Electronic Billing’.
  2. Create a non-claimed bill for Guarantor 2.
  3. Validate that the 837 Report, Required Data Missing: Patient Claim Data link contains a message similar to: Full denial not yet received from prior Medicare A No-Pay Guarantor: Medicare Part A (5). (Loop: 2320 Segment: CAS).
  4. Close the report.
  5. Close the form.
  6. Open ‘835 Health Care Claim Payment/Advice’.
  7. Load, compile and post the 835 mocked up in Setup.
  8. Close the report.
  9. Close the form.
  10. Create a query of the ‘SYSTEM.medicare_a_hold’ table specific to the client.
  11. Validate that no results are returned for the query.
  12. Open ‘Electronic Billing’.
  13. Create 837 Institutional claims for Guarantor 2.
  14. Validate that the 837 Report, Required Data Missing: Patient Claim Data link does not exist.
  15. Validate that the claim was created in the Dump file.
  16. Close the report.
  17. Close the form.
  18. Open ‘Client Ledger’ and validate that Guarantor 2 contains a number in ‘CLAIM NUMBER’.
  19. Close the report.
  20. Close the form.
Scenario 2: Medicare A Service Hold Management
Specific Setup:
  • User Definition:
  • Tester has been given access to the 'Medicare A Service Hold Management' form.
  • Tester has been given access to the 'SYSTEM.medicare_a_hold' table.
  • Guarantors/Payors:
  • Guarantors/Payor:
  • Guarantor 1:
  • Select a Medicare A guarantor: Note the 'Guarantor Code', 'Guarantor Name' and 'Financial Class'.
  • Select 'Yes' in 'Generate No-Pay ##0 Claims'.
  • Select desired value in 'Include No-Pay ##0 Claims In Separate 837 File'.
  • Select desired values in 'Type of Service to Include in No-Pay ##0 Claims'.
  • Guarantor 2:
  • Select an existing guarantor to be the secondary guarantor in Financial Eligibility. Note the 'Guarantor Code', 'Guarantor Name' and 'Financial Class'.
  • Select desired value in 'Generate No-Pay ##0 Claims'.
  • In the 837 section, select 'Yes' in 'Bill Only When Full Denial Received For Medicare A No-Pay Guarantor'. Note: Services will be placed on hold during liability distribution until a full denial is received for the Medicare A guarantor in an 835.
  • Client:
  • Admission: An inpatient client is admitted. Note the client's id/name, program, and date of admission.
  • Financial Eligibility:
  • Guarantor 1 is the primary guarantor. Customize the guarantor plan to allow a portion of the service charge to distribute to Guarantor 2.
  • Guarantor 2 is the secondary guarantor, and the guarantor plan allows payment of the portion of the service charge distributed to Guarantor 2.
  • Client Charge Input: Room & Board charges are rendered to the client for a minimum of one day.
  • Client Ledger: Validate that the charges distributed to both guarantors.
  • Close the charges.
  • Create a query of the ‘SYSTEM.medicare_a_hold’ table specific to the client.
  • Validate that there is one row for each service and: ‘GUARANTOR_ID’ = Guarantor 2 guarantor code; ‘PATID’ = the client’s ID; and ‘medicare_a_id’ = Guarantor 1 guarantor code.
Steps
  1. Open 'Electronic Billing'.
  2. Create a non-claimed 837 Institutional bill for Guarantor 2.
  3. Validate that an error message is received stating 'Unable To Create 837-Institutional. Please Check The Error Report'.
  4. Print the report and open the 'Required Data Missing: Patient Claim Data' link.
  5. Validate that the error is similar to ‘Full denial not yet received from prior Medicare A No-Pay Guarantor: Medicare Part A (5). (Loop: 2320 Segment: CAS)’.
  6. Close the report.
  7. Close the form.
  8. Open 'Medicare A Service Hold Management'.
  9. Enter the desired 'Client ID'.
  10. Select the desired 'Episode Number'.
  11. Enter the desired 'From Service Date'.
  12. Enter the desired 'Through Service Date'/
  13. Enter 'Guarantor 2' in 'Guarantor'.
  14. Select 'Service' in 'Service or Claim'.
  15. Click [Select Service(s) or Claim(s)].
  16. Select the desired service in the 'Medicare A Holds' checklist.
  17. Click [OK].
  18. Click [Submit].
  19. Close the form.
  20. Refresh the menu.
  21. Create a query of the ‘SYSTEM.medicare_a_hold’ table specific to the client. Validate that the services selected in the 'Medicare A Holds' checklist are not in the table.
  22. Close the query.
  23. Open 'Electronic Billing'.
  24. Create a claimed 837 Institutional bill for Guarantor 2.
  25. Validate that the 'Compile Complete' message is received.
  26. Print the report and open the '837 Institutional Submission' link.
  27. Verify that the services selected in the 'Medicare A Holds' checklist are included in the bill.
  28. Close the report.
  29. Close the form.
  30. Open 'Client Ledger' for the client and verify that the claims were created.
  31. Close the report.
  32. Close the form.
Scenario 3: Guarantors/Payors Web Service - Verification of AddGuarantorsPayors and UpdateGuarantorsPayors filing
Specific Setup:
  • External application utilizing Avatar PM Guarantors/Payors web service 'AddGuarantorsPayors' and 'UpdateGuarantorsPayors' methods/functions.
Steps
  1. Using the Avatar PM Guarantors/Payors web service (WEBSVC.GuarantorsPayors.cls), ensure that the following items/elements are added to the web service definition for AddGuarantorsPayors methods:
  2. GuarantorName (field 'Guarantor Name')
  3. GuarNameForAlphaLookup (field 'Guarantor Name For Alpha Lookup')
  4. NewGuarantorCode (field 'New Guarantor Code')
  5. FinancialClass (field 'Financial Class')
  6. GuarantorNature (field 'Guarantor Nature')
  7. ValueIn837P2300K301 (field 'Value to Include in 837P (2300-K3-01)')
  8. Copy2010BATo837P2330ANM1 (field 'Copy 837P-2010BA-NM1/N3/N4 to 837P-2330A-NM1/N3/N4')
  9. Copy1000ATo837P2330BNM1 (field 'Copy 837P-1000A-NM1 to 837P-2330B-NM1')
  10. UseGenDate837P2330BDTP03 (field 'Use File Generation Date in 837P-2330B-DTP-03')
  11. IncOthPayClmCNum837P2330B (field 'Include Other Payer Claim Control Number (837P-2330B-REF)')
  12. UseGenDate837P2430DTP03 (field 'Use File Generation Date in 837P-2430-DTP-03')
  13. ValueIn837I2300K301 (field 'Value to Include in 837I (2300-K3-01)')
  14. UseGenDate837I2330BDTP03 (field 'Use File Generation Date in 837I-2330B-DTP-03')
  15. IncOthPayClmCNum837I2330B (field 'Include Other Payer Claim Control Number (837I-2330B-REF)')
  16. UseGenDate837I2430DTP03 (field 'Use File Generation Date in 837I-2430-DTP-03')
  17. AllowExtMatch (field 'Allow Extended Matching Criteria in 835 Remittance Posting') (835 section).
  18. Submit the 'AddGuarantorsPayors' web service request.
  19. In Guarantors/Payors web service response, ensure that successful filing confirmation message 'Guarantors/Payors web service has been filed successfully' is returned.
  20. Open 'Guarantors/Payors' form.
  21. Select Edit action in 'Add New or Edit Existing Guarantor' field and select Guarantor Code/Guarantor filed via web service.
  22. Validate the data in the 'Guarantors/Payors section.
  23. Navigate to '837' section of 'Guarantors/Payors' form.
  24. Ensure that values filed via web service for items/elements noted above are present in respective fields in 'Guarantors/Payors' form.
  25. Navigate to '835' section of 'Guarantors/Payors' form.
  26. Ensure that value filed via web service for item/element noted above is present in respective fields in 'Guarantors/Payors' form.
  27. Using the Avatar PM Guarantors/Payors web service (WEBSVC.GuarantorsPayors.cls), ensure that the following items/elements are added to the web service definition for UpdateGuarantorsPayors methodsUpdateGuarantorsPayors method:
  28. GuarantorName
  29. GuarNameForAlphaLookup
  30. GuarantorCode
  31. FinancialClass
  32. GuarantorNature
  33. Change the value of 'ValueIn837P2300K301 (field 'Value to Include in 837P (2300-K3-01)')'
  34. Submit the 'UpdateGuarantorsPayors' web service request.
  35. In Guarantors/Payors web service response, ensure that successful filing confirmation message 'Guarantors/Payors web service has been filed successfully' is returned.
  36. Open 'Guarantors/Payors' form.
  37. Select Edit action in 'Add New or Edit Existing Guarantor' field and select Guarantor Code/Guarantor filed via web service.
  38. Validate the data in the 'Guarantors/Payors section.
  39. Navigate to '837' section of 'Guarantors/Payors' form.
  40. Validate the data in 'ValueIn837P2300K301 (field 'Value to Include in 837P (2300-K3-01)')'.
  41. Close the form.
Topics
• 837 Institutional • Guarantor/Payors • NX • Web Services
Table Changes
Table Column Change
WEBSVC.GuarantorsPayorsObject BillFulDenialMedANoPayGua New
SYSTEM.medicare_a_hold new table