Avatar PM 2023 Update 176

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Product Requirements and Recommendations

Avatar PM required
RADplus required

Recommended Update Level

Avatar PM 2023 Monthly Release 2023.04.00
RADplus 2023 Monthly Release 2023.04.00

Product Update Description

The following issues are resolved: 1) The 'PLB Amount' column is not populated with a correct value on the 835 work screen launched from the '835 Health Care Claim Payment/Advice' form. 2) 835 remittance posting process will incorrectly transfer liability to NTST Default Payor (99999) if the next applicable guarantor after the billing guarantor meets their monthly maximum allowable limit due to prior claims.

Required Updates

None

Included Updates

151

Details

NEW0 CHANGED0 FIXED2

Fixed (2)

AV-93996 Details \| User Acceptance Tests 835 Healthcare Claim Payment/ Advice - PLB Total Resolves an issue to ensure that the 'PLB Total' that displays in the work screen of the '835 Healthcare Claim Payment/ Advice' form includes all the monetary amounts in the segment. KB0075636 v0.01	Topics • 835 Health Care Claim Payment/Advice • NX

AV-94264 Details \| User Acceptance Tests 835 Healthcare Claim Payment/ Advice - Liability Distribution Resolves an issue to ensure that the amount over the sliding fee scale limit for the guarantor is transferring to correct guarantor according to the guarantor order. KB0075628 v0.01	Topics • 835 Health Care Claim Payment/Advice • NX

Acceptance Tests

AV-93996 Summary | Details

835 Healthcare Claim Payment/ Advice - PLB Total

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)
Claim Adjustment Group/Reason Code Definition
Client Charge Input (Charge Fee Access)
Client Ledger
Create Interim Billing Batch File
Crystal Report Viewer
Diagnosis
Electronic Billing
Financial Eligibility
Guarantors/Payors
Service Fee/Cross Reference Maintenance
Dynamic Form - Admission - Client
Dynamic Form - Edit Service Fee Definition

Scenario 1: 835 Health Care Claim Payment/Advice - Work Screen Grid

Specific Setup:

Claim Adjustment Group/ reason code Definition:
A group code is selected for the credit adjustment code and debit adjustment reversal code. Note the adjustment codes and group code setup.
Admission:
Admit a client into an outpatient episode. Note the Client id/name, Admission date/program.
Guarantor/Payors:
Three existing commercial guarantors are identified. Note the guarantors codes/names.
Financial Eligibility:
Three guarantors identified above are assigned to the client. Note the primary, secondary and tertiary guarantor.
Client Charge Input:
Three services rendered to the client in a same month. Note the service dates.
Client Ledger:
Make sure the services are distributed to the primary guarantors assigned to the client.
Close charges.
Electronic Billing:
The services are claimed using the 837 Professional bill for the primary guarantor.
Create an 835 file based on the claim information found in the 837 professional bill.

Steps

Open the '835 Health Care Claim Payment/Advice' form.
Load and compile the 835 file created that includes the claim for the defined guarantor in the setup.
Verify the 835 file loads/compiles successfully.
Select the 'Work Compile' option.
Select the compiled 835 file.
Click [Launch Work Screen].
Verify the 'PLB Amount' cell includes all the monetary amounts in the PLB to generate a correct total.
Click [Save].
Validate message "Save Successful' is displayed.
Click [Yes] to exit the grid.
Close the form.

Scenario 2: 835 Healthcare Claim Payment/Advise - Validating liability distribution after 'Monthly Maximum Responsibility' distributed

Specific Setup:

Claim Adjustment Group/ reason code Definition:
The desired group code is selected for the credit adjustment code and credit transfer code. Note the adjustment codes and group code setup.
Admission:
Admit a client into an outpatient episode. Note the Client id/name, Admission date/program.
Guarantor/Payors:
Three existing commercial guarantors are identified. Note the guarantors codes/names.
Financial Eligibility:
Three guarantors identified above are assigned to the client. Note the primary, secondary and tertiary guarantor.
The secondary guarantor is customized such that Monthly Maximum Responsibility field has a desired value. This means that once the amount entered in the Monthly Maximum Responsibility is distributed to the secondary guarantor for the month, anything else go to tertiary guarantor.
Client Charge Input:
Three services rendered to the client in a same month. Note the service dates.
Client Ledger:
Make sure the services are distributed to the primary guarantors assigned to the client.
Close charges.
Electronic Billing:
The services are claimed using the 837 Professional bill for the primary guarantor.
Create an 835 file based on the claim information found in the 837 professional bill.

Steps

Open the '835 Health Care Claim Payment/Advice' form.
Load and compile the 835 file created that includes the claims for the defined guarantor in the setup.
Verify the 835 file loads/compiles successfully.
Select 'Post File' option.
Select the file that is recently compiled successfully.
Populate all the required fields with desired value.
Verify the file posts successfully.
Open the 'Client Ledger' for the client.
Verify the amount entered in the 'Monthly Maximum Responsibility' is distributed to the secondary guarantor for the month and remaining amount distributed to the tertiary guarantor.

Topics

• 835 Health Care Claim Payment/Advice • NX

AV-94264 Summary | Details

835 Healthcare Claim Payment/ Advice - Liability Distribution

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)
Claim Adjustment Group/Reason Code Definition
Client Charge Input (Charge Fee Access)
Client Ledger
Create Interim Billing Batch File
Crystal Report Viewer
Diagnosis
Electronic Billing
Financial Eligibility
Guarantors/Payors
Service Fee/Cross Reference Maintenance
Dynamic Form - Admission - Client
Dynamic Form - Edit Service Fee Definition

Scenario 1: 835 Health Care Claim Payment/Advice - Work Screen Grid

Specific Setup:

Claim Adjustment Group/ reason code Definition:
A group code is selected for the credit adjustment code and debit adjustment reversal code. Note the adjustment codes and group code setup.
Admission:
Admit a client into an outpatient episode. Note the Client id/name, Admission date/program.
Guarantor/Payors:
Three existing commercial guarantors are identified. Note the guarantors codes/names.
Financial Eligibility:
Three guarantors identified above are assigned to the client. Note the primary, secondary and tertiary guarantor.
Client Charge Input:
Three services rendered to the client in a same month. Note the service dates.
Client Ledger:
Make sure the services are distributed to the primary guarantors assigned to the client.
Close charges.
Electronic Billing:
The services are claimed using the 837 Professional bill for the primary guarantor.
Create an 835 file based on the claim information found in the 837 professional bill.

Steps

Open the '835 Health Care Claim Payment/Advice' form.
Load and compile the 835 file created that includes the claim for the defined guarantor in the setup.
Verify the 835 file loads/compiles successfully.
Select the 'Work Compile' option.
Select the compiled 835 file.
Click [Launch Work Screen].
Verify the 'PLB Amount' cell includes all the monetary amounts in the PLB to generate a correct total.
Click [Save].
Validate message "Save Successful' is displayed.
Click [Yes] to exit the grid.
Close the form.

Scenario 2: 835 Healthcare Claim Payment/Advise - Validating liability distribution after 'Monthly Maximum Responsibility' distributed

Specific Setup:

Claim Adjustment Group/ reason code Definition:
The desired group code is selected for the credit adjustment code and credit transfer code. Note the adjustment codes and group code setup.
Admission:
Admit a client into an outpatient episode. Note the Client id/name, Admission date/program.
Guarantor/Payors:
Three existing commercial guarantors are identified. Note the guarantors codes/names.
Financial Eligibility:
Three guarantors identified above are assigned to the client. Note the primary, secondary and tertiary guarantor.
The secondary guarantor is customized such that Monthly Maximum Responsibility field has a desired value. This means that once the amount entered in the Monthly Maximum Responsibility is distributed to the secondary guarantor for the month, anything else go to tertiary guarantor.
Client Charge Input:
Three services rendered to the client in a same month. Note the service dates.
Client Ledger:
Make sure the services are distributed to the primary guarantors assigned to the client.
Close charges.
Electronic Billing:
The services are claimed using the 837 Professional bill for the primary guarantor.
Create an 835 file based on the claim information found in the 837 professional bill.

Steps

Open the '835 Health Care Claim Payment/Advice' form.
Load and compile the 835 file created that includes the claims for the defined guarantor in the setup.
Verify the 835 file loads/compiles successfully.
Select 'Post File' option.
Select the file that is recently compiled successfully.
Populate all the required fields with desired value.
Verify the file posts successfully.
Open the 'Client Ledger' for the client.
Verify the amount entered in the 'Monthly Maximum Responsibility' is distributed to the secondary guarantor for the month and remaining amount distributed to the tertiary guarantor.

Topics

• 835 Health Care Claim Payment/Advice • NX