Avatar PM 2023 Update 58

• Avatar PM Registry Setting 'Enable 834 Transaction Set' must be enabled
• 834 Benefit Enrollment Maintenance eligibility file for loading/compilation/posting in Avatar PM system, including one or more valid health coverage details
• Crystal Reports or other SQL reporting tool

1. Open Avatar PM 'Benefit Enrollment and Maintenance (834)' form.
2. Select 'Load File' in 'Options' field, and enter 'File Path/Name' value for 834 file to be loaded - selecting inbound 834 file including one or valid more health coverage details.
3. Select 'Compile File' in 'Options' field, and select loaded 834 file for compilation.
4. Click 'Process File' button to compile inbound 834 file data.
5. Select 'Run Report' in 'Options' field, and select compiled 834 file for report.
6. Click 'Process File' button to open 834 inbound compile report.
7. In 834 inbound compile report - ensure that in case where 2300-DTP Expiration Date is included without 2300-DTP Effective Date in health coverage detail and previously posted 834 coverage information for same Unique ID/Policy Number and Coverage Expiration Date exist in Avatar PM (existing information in SQL table 'SYSTEM.eligibility_dependent_cov'), inbound 834 health care coverage entry is successfully compiled.
8. Note - 'Coverage Effective Date' and/or 'Coverage Expiration Date' values may also be determined by Avatar PM Guarantor/Payor in cases where not directly present in 834 file health coverage information (via 'Default Benefit Effective Date (2300-DTP-03)' and/or 'Default Expiration Date (2300-DTP-03)' fields in Avatar PM 'Guarantors/Payors' form, '270 / 271 / 834' section)
9. In 834 inbound compile report - ensure that in case where 2300-DTP Effective Date and 2300-DTP Expiration Date are included for same Unique ID/Policy Number under separate/different 2000 loop sets, inbound 834 health care coverage entry is successfully compiled (using 2300-DTP Effective Date and 2300-DTP Expiration Date values from file where present).
10. Select 'Post File' in 'Options' field, and select compiled 834 file for posting.
11. Click 'Process File' button to post inbound 834 file data.
12. Open Crystal Reports or other SQL reporting tool.
13. In Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov', ensure that 'eligibility_eff_date' and 'eligibility_exp_date' values from 834 file health coverage information (or defaulted by Avatar PM system per Guarantor configurations) are present for eligibility data row(s) created via 834 inbound file posting.

1. Open 'Registry Settings' form.
2. Enter search value 'Use 2300-DTP with 303 Qualifier as Effective Date' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Use 2300-DTP with 303 Qualifier as Effective Date' is returned (under 'Avatar PM -> Billing -> Electronic Submissions -> Benefit Enrollment and Maintenance (834)' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"When set to 'Y' if a date is found in the 2300-DTP segment with a qualifier of 303 and a date is not found in the 2300-DTP segment with a qualifier of 348 the date with qualifier of 303 will be used as the effective date.

Select 'N' for the default functionality."

• Avatar PM Registry Setting 'Enable 834 Transaction Set' must be enabled
• Avatar PM Registry Setting 'Use 2300-DTP with 303 Qualifier as Effective Date' must be enabled
• 834 Benefit Enrollment Maintenance eligibility file for loading/compilation/posting in Avatar PM system, including one or more health coverage details where 2300-DTP*348 (Benefit Begin Date) is not included and 2300-DTP*303 (Maintenance Effective Date) is included
• Crystal Reports or other SQL reporting tool

1. Open Avatar PM 'Benefit Enrollment and Maintenance (834)' form.
2. Select 'Load File' in 'Options' field, and enter 'File Path/Name' value for 834 file to be loaded - selecting inbound 834 file including one or more health coverage details where 2300-DTP*348 (Benefit Begin Date) is not included and 2300-DTP*303 (Maintenance Effective Date) is included.
3. Select 'Compile File' in 'Options' field, and select loaded 834 file for compilation.
4. Click 'Process File' button to compile inbound 834 file data.
5. Select 'Run Report' in 'Options' field, and select compiled 834 file for report.
6. Click 'Process File' button to open 834 inbound compile report.
7. In 834 inbound compile report - ensure that in case where 2300-DTP*348 (Benefit Begin Date) is not included and 2300-DTP*303 (Maintenance Effective Date) is included in health coverage detail, 'Coverage Period Effective Date' (under 'Compiled Data' section of report) is defined with Maintenance Effective Date 2300-DTP*303 value from 834 information; ensure that where 2300-DTP*348 (Benefit Begin Date) is included in 834 health coverage detail, this value is used as 'Coverage Period Effective Date' over Maintenance Effective Date 2300-DTP*303 value.
8. Select 'Post File' in 'Options' field, and select compiled 834 file for posting.
9. Click 'Process File' button to post inbound 834 file data.
10. Open Crystal Reports or other SQL reporting tool.
11. In Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov', ensure that 'eligibility_eff_date' value as determined by either 2300-DTP*303 (Maintenance Effective Date) or 2300-DTP*348 (Benefit Begin Date) value in health coverage detail is present for eligibility data row(s) created via 834 inbound file posting.

• Avatar PM Registry Setting 'Enable 834 Transaction Set' must be enabled

1. Open the Avatar PM 'Guarantors/Payors' form.
2. Select Add or Edit action in 'Add New or Edit Existing Guarantor' field.
3. Enter new (or select existing) Guarantor Code.
4. Complete all required/desired fields in main section of 'Guarantors/Payors' form.
5. Navigate to '270 / 271 / 834' section of 'Guarantors/Payors' form.
6. Ensure that the 'Default Benefit Effective Date (2300-DTP-03)' field is available in form, with 'Beginning of the Expiration Date Month' checkbox/selection available.
7. If 'Beginning of the Expiration Date Month' is selected in this field, 834 Benefit Enrollment and Maintenance compilation/posting will use beginning/first day of Coverage Expiration Date month value from health coverage information detail as Coverage Effective Date where 2300-DTP*348 (Benefit Begin Date) and/or 2300-DTP*303 (Maintenance Effective Date) is/are not included.
8. Select 'Beginning of the Expiration Date Month' value in 'Default Benefit Effective Date (2300-DTP-03)' field (and any other desired fields in '270 / 271 / 834' section of form).
9. Navigate to main section of 'Guarantors/Payors' form.
10. Click 'File' button to save/file Guarantor/Payor definition information.
11. Select 'Edit' action and select previously filed Guarantor Code.
12. Navigate to '270 / 271 / 834' section of 'Guarantors/Payors' form.
13. Ensure that previously selected/filed value for 'Default Benefit Effective Date (2300-DTP-03)' field is present/selected in form.

• Avatar PM Registry Setting 'Enable 834 Transaction Set' must be enabled
• Avatar PM Registry Setting 'Use 2300-DTP with 303 Qualifier as Effective Date' may optionally be enabled/disabled
• 'Beginning of the Expiration Date Month' must be selected/enabled in the 'Default Benefit Effective Date (2300-DTP-03)' field for applicable 834 Guarantor (via Avatar PM 'Guarantors/Payors' form, '270 / 271 / 834' section)
• 834 Benefit Enrollment Maintenance eligibility file for loading/compilation/posting in Avatar PM system, including one or more health coverage details where 2300-DTP*348 (Benefit Begin Date) and/or 2300-DTP*303 (Maintenance Effective Date) are not included
• Crystal Reports or other SQL reporting tool

1. Open Avatar PM 'Benefit Enrollment and Maintenance (834)' form.
2. Select 'Load File' in 'Options' field, and enter 'File Path/Name' value for 834 file to be loaded - selecting inbound 834 file including one or more health coverage detail where 2300-DTP*348 (Benefit Begin Date) and/or 2300-DTP*303 (Maintenance Effective Date) are not included.
3. Note - Use of 2300-DTP*303 (Maintenance Effective Date) to determine Coverage Period Effective Date where included/not included is dependent on Avatar PM Registry Setting 'Use 2300-DTP with 303 Qualifier as Effective Date'
4. Select 'Compile File' in 'Options' field, and select loaded 834 file for compilation.
5. Click 'Process File' button to compile inbound 834 file data.
6. Select 'Run Report' in 'Options' field, and select compiled 834 file for report.
7. Click 'Process File' button to open 834 inbound compile report.
8. In 834 inbound compile report - ensure that in case where 2300-DTP*348 (Benefit Begin Date) and/or 2300-DTP*303 (Maintenance Effective Date) are not included in health coverage detail, 'Coverage Period Effective Date' (under 'Compiled Data' section of report) is defined with beginning/first date of month from Coverage Period Expiration Date/Benefit End Date 2300-DTP*349 value from 834 information; ensure that where 2300-DTP*348 (Benefit Begin Date) and/or 2300-DTP*303 (Maintenance Effective Date) is/are included in 834 health coverage detail, this value is used as 'Coverage Period Effective Date' over 'Beginning of the Expiration Date Month' defaulting value.
9. Examples:
10. If 834 Coverage Information includes Coverage Expiration Date 2300-DTP*349 value '06/30/2023', '06/15/2023' or '06/01/2023'
11. 'Coverage Period Effective Date' value under 'Default Benefit Effective Date (2300-DTP-03)'/'Beginning of the Expiration Date Month' function set to '06/01/2023'
12. If 834 Coverage Information includes Coverage Expiration Date 2300-DTP*349 value '04/30/2023', '04/25/2023' or '04/02/2023'
13. 'Coverage Period Effective Date' value under 'Default Benefit Effective Date (2300-DTP-03)'/'Beginning of the Expiration Date Month' function set to '04/01/2023'
14. Select 'Post File' in 'Options' field, and select compiled 834 file for posting.
15. Click 'Process File' button to post inbound 834 file data.
16. Open Crystal Reports or other SQL reporting tool.
17. In Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov', ensure that 'eligibility_eff_date' value as determined by 'Default Benefit Effective Date (2300-DTP-03)'/'Beginning of the Expiration Date Month' function (or 2300-DTP*348 Benefit Begin Date / 2300-DTP*303 Maintenance Effective Date information) in health coverage detail is present for eligibility data row(s) created via 834 inbound file posting.

1. Open 'Registry Settings' form.
2. Enter search value 'Plan Coverage Description (2300-HD-04)' and click 'View Registry Settings' button.
3. Ensure Registry Setting 'Plan Coverage Description (2300-HD-04)' is returned (under 'Avatar PM -> Billing -> Electronic Submissions -> Benefit Enrollment and Maintenance' path).
4. Ensure 'Registry Setting Details' field contains the following explanation text:

"Selecting 'Y' will activate the following logic: A new field 'Plan Coverage Description (2300-HD-04)' will be added to the '270/271/834' tab of the 'Guarantors/Payors' form. When an 834 file is processed, the value in the Plan Coverage Description (2300-HD-04) field in the file will be compared against the value in the 'Plan Coverage Description (2300-HD-04)' field on the form to determine the eligible guarantor(s) for the specified coverage.

The above logic will compare the entire value in the Plan Coverage Description (2300-HD-04) field. To compare a specific piece of data in Plan Coverage Description (2300-HD-04) in the 834 file against the entire value of the field on the form, the registry setting value can be defined as 'Y[D]elimiter[P]iece', where 'Y' enables the logic, 'Delimiter' determines the separator character between each piece of data, and 'Piece' determines the piece of the data to examine. If the 'Delimiter' is '0' (zero), then positional logic will be used and the 'Piece' portion will be the character position(s) to use.

Example:

'Y-2' will extract the string 'BBB' from a Plan Coverage Description (2300-HD-04) value of 'AAA-BBB-CCC-DDD' and compare against the field on the form.

'Y04' will extract the character 'D' from a value of 'ABCDEF'.

'Y04-5' will extract the string 'DE' from a value of 'ABCDEF'.

Selecting 'N' disables this logic and removes the field from the form.

Note: Enabling this registry setting and specifying a value in the 'Plan Coverage Description (2300-HD-04)' field on the 'Guarantors/Payors' form will override the logic to utilize the 'Insurer Identifier Code (1000B-N1-04)' field for guarantor determination. However, the 'Insurer Identifier Code (1000B-N1-04)' will still be used to specify the guarantor for any coverage levels where the 2300-HD-04 value does not have a match on file.

Note: Replace 'Y' with 'B' to determine guarantor using both 'Plan Coverage Description (2300-HD-04)' and 'Insurer Identifier Code (1000B-N1-04)'."

• Avatar PM Registry Setting 'Enable 834 Transaction Set' must be enabled
• Avatar PM Registry Setting 'Plan Coverage Description (2300-HD-04)' must be enabled with 1000B-N1/2300-HD ('B') or 2300-HD ('Y') value
• Examples: 'B', 'B04', 'B04-5', 'B-4' ,' Y', 'Y04', 'Y04-5', 'Y-4'
• 'Insurer Identifier Code (1000B-N1-04)' and/or 'Plan Coverage Description (2300-HD-04)' values must be defined for applicable 834 Guarantor (via Avatar PM 'Guarantors/Payors' form, '270 / 271 / 834' section)
• 834 Benefit Enrollment Maintenance eligibility file for loading/compilation/posting in Avatar PM system, including one or more valid health coverage details
• Crystal Reports or other SQL reporting tool

1. Open Avatar PM 'Benefit Enrollment and Maintenance (834)' form.
2. Select 'Load File' in 'Options' field, and enter 'File Path/Name' value for 834 file to be loaded - selecting inbound 834 file including one or valid more health coverage details.
3. Select 'Compile File' in 'Options' field, and select loaded 834 file for compilation.
4. Click 'Process File' button to compile inbound 834 file data.
5. Select 'Run Report' in 'Options' field, and select compiled 834 file for report.
6. Click 'Process File' button to open 834 inbound compile report.
7. In 834 inbound compile report - Where Registry Setting 'Plan Coverage Description (2300-HD-04)' is enabled with value including 'B', ensure that Guarantor/Payor applicable to inbound 834 health coverage information/details is determined by both 834 Insurer Identifier Code (1000B-N1-04) and Plan Coverage Description (2300-HD-04) values compared to 'Insurer Identifier Code (1000B-N1-04)' and 'Plan Coverage Description (2300-HD-04)' values in Avatar PM 'Guarantors/Payors' form (respectively).
8. In case where both 834 Insurer Identifier Code (1000B-N1-04) and Plan Coverage Description (2300-HD-04) values match 'Insurer Identifier Code (1000B-N1-04)' and 'Plan Coverage Description (2300-HD-04)' values for Guarantor, ensure that Guarantor is present in 834 inbound compile/post report data (under 'Compiled Data' section of report)
9. Note - 834 file Plan Coverage Description (2300-HD-04) values will be parsed/extracted as detailed for 'Plan Coverage Description (2300-HD-04)' Registry Setting if parsing is enabled via additional entry beyond 'B' value in Registry Setting (Ex: 'B04', 'B04-5')
10. Note - Where Registry Setting 'Plan Coverage Description (2300-HD-04)' is enabled with value including 'B' - In case where 834 Plan Coverage Description (2300-HD-04) value matches 'Plan Coverage Description (2300-HD-04)' value for Guarantor, 834 Insurer Identifier Code (1000B-N1-04) must also match 'Insurer Identifier Code (1000B-N1-04)' value for same Guarantor for 834 compilation/posting under Guarantor
11. In case where 834 Plan Coverage Description (2300-HD-04) value does not match to any Guarantor but 834 Insurer Identifier Code (1000B-N1-04) value matches 'Insurer Identifier Code (1000B-N1-04)' value for Guarantor, ensure that Guarantor is present in 834 inbound compile/post report data (under 'Compiled Data' section of report)
12. In case where 834 Plan Coverage Description (2300-HD-04) value matches 'Plan Coverage Description (2300-HD-04)' value for Guarantor but 834 Insurer Identifier Code (1000B-N1-04) value does not match to Guarantor, ensure that Error Message 'Unable to determine guarantor from loop 1000B or loop 2300 information' is returned by 837 compilation/posting (under 'Errors Associated With Compilation' section of report)
13. In case where Guarantor cannot be determined by a match to both Insurer Identifier Code (1000B-N1-04) and Plan Coverage Description (2300-HD-04) values, ensure that Error Message 'Unable to determine guarantor from loop 1000B or loop 2300 information' is returned by 837 compilation/posting (under 'Errors Associated With Compilation' section of report)
14. In 834 inbound compile report - Where Registry Setting 'Plan Coverage Description (2300-HD-04)' is enabled with value including 'Y', ensure that Guarantor/Payor applicable to inbound 834 health coverage information/details is determined by 834 Plan Coverage Description (2300-HD-04) value compared to 'Plan Coverage Description (2300-HD-04)' value in Avatar PM 'Guarantors/Payors' form (and Guarantor is only determined by 834 Insurer Identifier Code (1000B-N1-04) value where no Plan Coverage Description (2300-HD-04) Guarantor match is found).
15. In case where 834 Plan Coverage Description (2300-HD-04) value matches 'Plan Coverage Description (2300-HD-04)' value for Guarantor, ensure that Guarantor is present in 834 inbound compile/post report data (under 'Compiled Data' section of report)
16. Note - 834 file Plan Coverage Description (2300-HD-04) values will be parsed/extracted as detailed for 'Plan Coverage Description (2300-HD-04)' Registry Setting if parsing is enabled via additional entry beyond 'Y' value in Registry Setting (Ex: 'Y04', 'Y04-5')
17. Note - Where Registry Setting 'Plan Coverage Description (2300-HD-04)' is enabled with value including 'Y' - In case where 834 Plan Coverage Description (2300-HD-04) value matches 'Plan Coverage Description (2300-HD-04)' value for Guarantor, 834 Insurer Identifier Code (1000B-N1-04) is not required to match 'Insurer Identifier Code (1000B-N1-04)' value for same Guarantor
18. In case where 834 Plan Coverage Description (2300-HD-04) value does not match to any Guarantor but 834 Insurer Identifier Code (1000B-N1-04) value matches 'Insurer Identifier Code (1000B-N1-04)' value for Guarantor, ensure that Guarantor is present in 834 inbound compile/post report data (under 'Compiled Data' section of report)
19. In case where Guarantor cannot be determined by a match to Plan Coverage Description (2300-HD-04) and/or Insurer Identifier Code (1000B-N1-04) values, ensure that Error Message 'Unable to determine guarantor from loop 1000B or loop 2300 information' is returned by 837 compilation/posting (under 'Errors Associated With Compilation' section of report)
20. In 834 inbound compile report - Where Registry Setting 'Plan Coverage Description (2300-HD-04)' is disabled, ensure that Guarantor/Payor applicable to inbound 834 health coverage information/details is determined by 834 Insurer Identifier Code (1000B-N1-04) value compared to 'Insurer Identifier Code (1000B-N1-04)' value in Avatar PM 'Guarantors/Payors' form.
21. In case where Guarantor cannot be determined by a match of Insurer Identifier Code (1000B-N1-04) value, ensure that Error Message 'Unable to determine guarantor from loop 1000B information' is returned by 837 compilation/posting (under 'Errors Associated With Compilation' section of report)
22. Select 'Post File' in 'Options' field, and select compiled 834 file for posting.
23. Click 'Process File' button to post inbound 834 file data.
24. Open Crystal Reports or other SQL reporting tool.
25. In Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov', ensure that 'GUARANTOR_ID' value as determined by Insurer Identifier Code (1000B-N1-04) and/or Plan Coverage Description (2300-HD-04) in health coverage detail is present for eligibility data row(s) created via 834 inbound file posting.

• Avatar PM Registry Setting 'Enable 834 Transaction Set' must be enabled
• 834 Benefit Enrollment Maintenance eligibility file for loading/compilation/posting in Avatar PM system
• Crystal Reports or other SQL reporting tool

1. Open Avatar PM 'Benefit Enrollment and Maintenance (834)' form.
2. Select 'Load File' in 'Options' field, and enter 'File Path/Name' value for 834 file to be loaded.
3. Select 'Compile File' in 'Options' field, and select loaded 834 file for compilation.
4. Click 'Process File' button to compile inbound 834 file data.
5. Select 'Run Report' in 'Options' field, and select compiled 834 file for report.
6. Click 'Process File' button to open 834 inbound compile report.
7. In 834 inbound compile report, ensure that one or more coverage periods from file are successfully compiled.
8. Select 'Post File' in 'Options' field, and select compiled 834 file for posting.
9. Click 'Process File' button to post inbound 834 file data.
10. Close 'Benefit Enrollment and Maintenance (834)' form.
11. Open Crystal Reports or other SQL reporting tool.
12. In Avatar PM SQL table 'SYSTEM.eligibility_subscriber', ensure that values for following added fields are present/populated based on 834 inbound information/values (where values present in 834 file data):
13. 'cust_par_comm_1' / 'cust_par_comm_2' / 'cust_par_comm_3'
14. 'cust_par_comm_qua_1_code' / 'cust_par_comm_qua_2_code' / 'cust_par_comm_qua_3_code'
15. 'cust_parent_contact_code'
16. 'cust_parent_id' / 'cust_parent_id_code' / 'cust_parent_id_qua_code'
17. 'cust_parent_name_first' / 'cust_parent_name_last' / 'cust_parent_name_mid'
18. 'cust_parent_name_pre' / 'cust_parent_name_suf'
19. 'cust_parent_type_qua_code'
20. 'cust_par_address' / 'cust_par_address_2'
21. 'cust_par_city' / 'cust_par_country' / 'cust_par_coun_sub_div'
22. 'cust_par_state' / 'cust_par_zip'
23. 'location_qualifier' / 'location_ident'
24. 'health_related_code'
25. 'resp_per_address' / 'resp_per_address_2'
26. 'resp_per_city' / 'resp_per_country' / 'resp_per_coun_sub_div'
27. 'resp_per_state' / 'resp_per_zip'
28. In Avatar PM SQL table 'SYSTEM.eligibility_demographics', ensure that values for following added fields are present/populated based on 834 inbound information/values (where values present in 834 file data):
29. 'date_of_death'
30. 'language_desc'
31. 'language_use_indicator'
32. In Avatar PM SQL table 'SYSTEM.eligibility_dependent_cov', ensure that value for following added field is present/populated based on 834 inbound information/values (where values present in 834 file data):
33. 'reference_identification'
34. In Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cob', ensure that rows are filed/present based on 834 inbound information/values from 2320 Coordination Of Benefits loop (where 2320 loop/values present in 834 file data).
35. In Avatar PM SQL table 'SYSTEM.eligibility_dep_cov_cobre', ensure that rows are filed/present based on 834 inbound information/values from 2330 Coordination Of Benefits Related Entity loop (where 2330 loop/values present in 834 file data).