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Avatar PM 2023 Update 33

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Product Requirements / Recommendations

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Product Update Form Description

The extended dictionary 'CCBHC Billing - Exclude from check for remittance from private insurance' ('Payor' file data element 1700) off of 'Financial Class' ('Payor' file data element 1000) is introduced. If the value of the new extended dictionary is set to 'Y' for a financial class, and claims grouping is being used, the CCBHC billing process will skip the check for remittance received from private insurance for guarantors in the financial class. Note: The registry setting 'Enable CCBHC Functionality' must be set to 'E' in order to process CCBHC billing.

Included Updates

None

Required Updates

None

Details
NEW1 CHANGED0 FIXED0
New (1)
Dictionary Update - Payor
A new extended dictionary called 'CCBHC - Exclude from check for remittance from private insurance' will be added to the financial class dictionary in the Payor file.
Value Added: The extended dictionary will allow agencies to determine by financial class whether to include/exclude the check for remittance from private insurance.
Topics
• 837 Institutional • 837 Professional • CCBHC
 
Acceptance Tests
AV-86440 Summary | Details
Dictionary Update - Payor
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • Avatar NX Report Viewer
  • CCBHC PPS Compile
  • CCBHC PPS Service Definition
  • Client Charge Input
  • Client Ledger
  • Diagnosis
  • Dictionary Update (PM)
  • Electronic Billing
  • Financial Eligibility
  • Guarantors/Payors
  • Practitioner Numbers By Guarantor And Program
  • Program Maintenance
  • Registry Settings (PM)
  • Service Codes
  • Service Fee/Cross Reference Maintenance
  • Admission
  • Bed Availability Report
Scenario 1: CCBHC Billing - 837P - Exclude from check for remittance from private insurance.
Specific Setup:
  • CCBHC functionality is enabled and setup.
  • Dictionary Update: Payor
  • Print Dictionary - 1000 – Financial Class
  • Validate that the extended dictionary 'CCBHC Billing - Exclude from check for remittance from private insurance' has a value of ‘Y’ for the following financial classes: 3 (Medicaid), 6 (Self Pay), 7 (Medicare A), 8 (Medicare B).
  • Any financial class that has the ‘System Financial Class set to a value of 3 (Medicaid), 6 (Self Pay), 7 (Medicare A), 8 (Medicare B), will also have a value of ‘Yes’ in the extended dictionary 'CCBHC Billing - Exclude from check for remittance from private insurance'.
  • Input Dictionary - 1000 – Financial Class
  • Select a financial class for a non CCBHC guarantor that does not have a value for the extended dictionary 'CCBHC Billing - Exclude from check for remittance from private insurance' and set the value to 'No'. This will be the client's primary guarantor.
  • Service Codes
  • Identify a code that is a CCBHC service and a CCBHC Enumerated Service.
  • Identify a code that is a CCBHC service and is not a CCBHC Enumerated Service.
  • Client: Identify an outpatient client with the following:
  • Financial Eligibility:
  • Client is assigned the guarantor with the 'CCBHC Billing - Exclude from check for remittance from private insurance' dictionary value of 'No' as the primary guarantor. Setup will cover the enumerated service and force the non enumerated service to the secondary guarantor.
  • Client is assigned a CCBHC guarantor as the secondary guarantor.
  • Services: Client has one or more services for the code that is a CCBHC service and a CCBHC Enumerated Service. The services must be closed.
  • Client Ledger was used to verify that the services distributed to the primary guarantor.
Steps
  1. Open 'CCBHC PPS Compile' and process the compile for the client.
  2. Print the report and validate that the non-enumerated service was created and distributed to the secondary guarantor.
  3. If desired, open ‘Client Ledger’ and verify that the non-enumerated service distributed to the secondary guarantor.
  4. Open ‘Close Charges’ and close the charges for the client.
  5. Open ‘Electronic Billing’.
  6. Select '837-Professional' in 'Billing Type'.
  7. Process the bill for the primary funding source. The services can be claimed or unclaimed. If necessary, include CCBHC services.
  8. Validate that the ‘Compile Complete’ message is received.
  9. If desired, review the dump file or print the report.
  10. Process the bill for the secondary guarantor. Do not create claims. Include CCBHC services.
  11. Validate that the ‘No Valid Information Found. Please Check The Error Report’ message is received.
  12. Print the report to review the error message.
  13. Click the ‘Required Data Missing: Header and/or Billing/Pay-to Provider Data’ link and verify that the message is: Service ‘xxx’ Service Code (xxx) [date] is still awaiting remittance from private insurance.
  14. Click the Required Data Missing: Patient Claim Data link and verify that the message is: PPS service ‘xxx (1250) [date] cannot be billed until all associated enumerated services are ready to bill.
  15. Close the report.
  16. Close the form.
  17. Open ‘Dictionary Update’
  18. Select the ‘Payor’ file.
  19. Select dictionary ‘Financial Class’, # 1000.
  20. Access the financial class for the primary guarantor.
  21. Change the 'CCBHC Billing - Exclude from check for remittance from private insurance' value to ‘Yes’.
  22. Apply the changes.
  23. Exit the form.
  24. Open ‘Electronic Billing’.
  25. Process the bill for the secondary guarantor. The services can be claimed or unclaimed.
  26. Validate that the ‘Compile Complete’ message is received.
  27. If desired, review the dump file or print the report.
Scenario 2: CCBHC Billing - 837I - Exclude from check for remittance from private insurance.
Specific Setup:
  • CCBHC functionality is enabled and setup.
  • Dictionary Update: Payor
  • Print Dictionary - 1000 – Financial Class
  • Validate that the extended dictionary 'CCBHC Billing - Exclude from check for remittance from private insurance' has a value of ‘Y’ for the following financial classes: 3 (Medicaid), 6 (Self Pay), 7 (Medicare A), 8 (Medicare B).
  • Any financial class that has the ‘System Financial Class set to a value of 3 (Medicaid), 6 (Self Pay), 7 (Medicare A), 8 (Medicare B), will also have a value of ‘Yes’ in the extended dictionary 'CCBHC Billing - Exclude from check for remittance from private insurance'.
  • Input Dictionary - 1000 – Financial Class
  • Select a financial class for a non CCBHC guarantor that does not have a value for the extended dictionary 'CCBHC Billing - Exclude from check for remittance from private insurance' and set the value to 'No'. This will be the client's primary guarantor.
  • Service Codes
  • Identify a code that is a CCBHC service and a CCBHC Enumerated Service.
  • Identify a code that is a CCBHC service and is not a CCBHC Enumerated Service.
  • Client: Identify an outpatient client with the following:
  • Financial Eligibility:
  • Client is assigned the guarantor with the 'CCBHC Billing - Exclude from check for remittance from private insurance' dictionary value of 'No' as the primary guarantor. Setup will cover the enumerated service and force the non enumerated service to the secondary guarantor.
  • Client is assigned a CCBHC guarantor as the secondary guarantor.
  • Services: Client has one or more services for the code that is a CCBHC service and a CCBHC Enumerated Service. The services must be closed.
  • Client Ledger was used to verify that the services distributed to the primary guarantor.
Steps
  1. Open 'CCBHC PPS Compile' and process the compile for the client.
  2. Print the report and validate that the non-enumerated service was created and distributed to the secondary guarantor.
  3. If desired, open ‘Client Ledger’ and verify that the non-enumerated service distributed to the secondary guarantor.
  4. Open ‘Close Charges’ and close the charges for the client.
  5. Open ‘Electronic Billing’.
  6. Select '837-Institutional' in 'Billing Type'.
  7. Process the bill for the primary funding source. The services can be claimed or unclaimed. If necessary, include CCBHC services.
  8. Validate that the ‘Compile Complete’ message is received.
  9. If desired, review the dump file or print the report.
  10. Process the bill for the secondary guarantor. Do not create claims. Include CCBHC services.
  11. Validate that the ‘No Valid Information Found. Please Check The Error Report’ message is received.
  12. Print the report to review the error message.
  13. Click the ‘Required Data Missing: Header and/or Billing/Pay-to Provider Data’ link and verify that the message is: Service ‘xxx’ Service Code (xxx) [date] is still awaiting remittance from private insurance.
  14. Click the Required Data Missing: Patient Claim Data link and verify that the message is: PPS service ‘xxx (1250) [date] cannot be billed until all associated enumerated services are ready to bill.
  15. Close the report.
  16. Close the form.
  17. Open ‘Dictionary Update’
  18. Select the ‘Payor’ file.
  19. Select dictionary ‘Financial Class’, # 1000.
  20. Access the financial class for the primary guarantor.
  21. Change the 'CCBHC Billing - Exclude from check for remittance from private insurance' value to ‘Yes’.
  22. Apply the changes.
  23. Exit the form.
  24. Open ‘Electronic Billing’.
  25. Process the bill for the secondary guarantor. The services can be claimed or unclaimed.
  26. Validate that the ‘Compile Complete’ message is received.
  27. If desired, review the dump file or print the report.
Topics
• 837 Institutional • 837 Professional • CCBHC