835 Health Care Claim Payment/Advice – Enable Extended Matching Criteria Functionality
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
- 835 Health Care Claim Payment/Advice (PM)
- Admission (Outpatient)
- Client Charge Input
- Client Ledger
- Crystal Report Viewer
- Diagnosis
- Electronic Billing
- Financial Eligibility
- Guarantors/Payors
- Program Maintenance
- Registry Settings (PM)
- Service Codes
- Service Fee/Cross Reference Maintenance
Scenario 1: 835 Health Care Claim Payment/Advice - Enable Extended Matching Criteria Functionality
Specific Setup:
- Registry Setting:
- ‘Avatar PM->Billing->Remittance Processing->835 Health Care Claim Payment/Advice->->Enable Extended Matching Criteria Functionality’ has a value of ‘Y’.
- Service Code:
- Service Code 1: There is a value of ‘Yes’ in ‘Include in 835 Extended Matching Criteria’.
- Service Code 2: There is no value, or a value of ‘No’ in ‘Include in 835 Extended Matching Criteria’.
- Guarantors/Payors:
- There is a value of ‘Yes’ in ‘Allow Extended Matching Criteria in 835 Remittance Posting’, which is in the 835 section of the form.
- Client:
- Identify an active client that is assigned the above Guarantors/Payors in Financial Eligibility.
- Client Charge Input:
- Service Code 1: Create at least one charge. Note the date.
- Service Code 2: Create at least one charge on a different date.
- Close Charges is used to close the charges for the client.
- Electronic Billing:
- Create a claim for Service Code 1. Save the dump file for use in modifying an 835.
- Create a separate claim for Service Code 2. Save the dump file for use in modifying an 835.
- Modify an existing 835 to create a valid payment for the claim for Service Code 1.
- Match a minimum of 2 out of 3 of these ‘Client’ elements: Client Name, Subscriber Policy Number or Social Security Number, and Subscriber Name (if subscriber is not the client).
- Match all of these ‘Service’ elements: Date of Service, Cost of Service, Procedure Code/Modifiers, and the Service Code is flagged to be included in 835 extended matching criteria.
- The claim number in the CLM segment should not match the claim number in the dump file.
- Save the file to a local directory.
- Modify an existing 835 to create a valid payment for the claim for Service Code 2.
- Match a minimum of 2 out of 3 of these ‘Client’ elements: Client Name, Subscriber Policy Number or Social Security Number, and Subscriber Name (if subscriber is not the client).
- Match all of these ‘Service’ elements: Date of Service, Cost of Service, Procedure Code/Modifiers, and the Service Code is flagged to be included in 835 extended matching criteria.
- The claim number in the CLM segment should not match the claim number in the dump file.
Steps
- Open '835 Health Care Claim Payment/Advice'.
- Load the file created for the 'Service Code 1' claim.
- Validate the message: There were errors on the file load. Please run the report to view these errors. Load complete.
- Run the report.
- Validate that the error message is a warning stating: Patient Control Number ’xxxxx’ not valid. Payment will be processed for claim number '[Actual Claim Number]' based on extended matching criteria.
- Compile the file.
- Verify the 'Compile Complete' message.
- Click [Payments and Adjustments (These Will Be Posted Except For Those Marked As 'Compile But Do Not Post].
- Verify the correct payment amount displays.
- Post the file.
- Verify the 'Posting Complete' message.
- Open the 'Client Ledger' form.
- Verify the 'Client Ledger' displays the payment posted correctly.
- Close the form.
- Load the file created for the 'Service Code 2' claim.
- Validate the message: There were errors on the file load. Please run the report to view these errors. Load complete.
- Compile the file and validate that the error message states: Claim does not exist in Avatar (Patient Control Number '[Claim Number from the 835 file]').
- Update the 835 file with the matching claim number from the 837 file created for the Service Code 2.
- Open '835 Health Care Claim Payment/Advice'.
- Load the file for the 'Service Code 2' claim.
- Verify the 'Load Complete' message.
- Compile the file.
- Verify the 'Compile Complete' message.
- Click [Payments and Adjustments (These Will Be Posted Except For Those Marked As 'Compile But Do Not Post')].
- Verify the report displays correct payment amount compiled.
- Post the file.
- Verify the 'Posting Complete' message.
- Close the form.
- Open the 'Client Ledger' form.
- Verify the 'Client Ledger' displays the payment posted correctly.
- Close the form.
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Topics
• 835 Health Care Claim Payment/Advice
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