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Avatar PM 2023 Update 85

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Product Requirements and Recommendations

Avatar PM required
RADplus required

Recommended Update Level

Avatar PM 2023 Monthly Release 2023.02.01
RADplus 2023 Monthly Release 2023.02.01

Product Update Description

The following issues are resolved: 1) The "[UNDEFINED]rp2+1^BICA" error might occur when posting contractual adjustments in the 'Contractual Allowance (Inpatient)' form. 2) 'Reference to functional group and transaction set number not created by Avatar' error message is incorrectly reported when processing a 999 Implementation Acknowledgement File in the 'Functional Or Implementation Acknowledgement (997/999)' form. 3) Deleting a generic eligibility inquiry via the 'Delete Inquiry' button in the 'Eligibility Inquiry (270) Request' form will not delete the selected inquiry. 4) Service modifier from the 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date' field on the 'Service Fee/Cross Reference Maintenance' form is incorrectly included on the 837 bill.

Required Updates

None

Included Updates

10, 17, 21, 25, 39, 44, 57, 62, 63, 66, 67, 73, 76, 77, 78, 79

Details
NEW0 CHANGED0 FIXED4
Fixed (4)
Client Ledger - Post Contractual Adjustments
Resolves an issue to ensure that the batch contractual adjustments are applied correctly after the claim is created while running quick billing task through system task scheduler. KB0073666 v0.01
Topics
• Contractual Allowance (Inpatient) • Contractual Allowance (Outpatient) • NX • Quick Billing • System Task Scheduler
 
Functional Or Implementation Acknowledgement (997/999) - Compiling the 999 file created from the 270 file
Resolves an issue to ensure that the 999 files created from 270 files compile successfully when the registry setting 'Maintain Unique Functional Group Control Numbers by Root System Code' is set to Y. KB0073992 v0.01
Topics
• Functional or Implementation Acknowledgement (997/999) • NX
 
Eligibility Inquiry 270 Request - Delete inquiry
Resolves an issue to ensure that the eligibility inquiry deleted successfully.
Topics
• Eligibility Inquiry (270) Request • NX
 
Service/Fee Cross Reference - CPT-4 / HCPCS Modifier If Not First Instance For Service Date
Resolves an issue to ensure that the 837 professional bill does not include the modifier from the 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date' field for the first instance of the service If the service is transferred to the secondary guarantor and then transferred back to the original guarantor. KB0073991 v0.01
Topics
• 837 Professional • NX
 
Acceptance Tests
AV-78369 Summary | Details
Client Ledger - Post Contractual Adjustments
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Client Ledger
  • System Task Scheduler
  • Admission
  • Admission (Outpatient)
  • Client Charge Input
  • Diagnosis
  • Financial Eligibility
  • Guarantors/Payors
  • Quick Billing
  • Quick Billing Rule Definition
  • Change MR#
  • Contractual Allowance (Inpatient)
  • Delete Last Movement
  • Delete Service
Scenario 1: Quick Billing Post Contractual Adjustments Task - System Task Scheduler
Specific Setup:
  • Registry Setting:
  • The 'Enable New Quick Billing Format' registry setting is set to 'Y'.
  • Guarantors/Payors:
  • A guarantor is added or edited such that it is defined as a 'Contract' guarantor in the 'Guarantor Nature' field.
  • Service Codes:
  • Add or edit new professional services that are defined as 'Per Diem' services. (Please note: Any inpatient services processed for Contractual Adjustment Posting that are not defined as 'Per Diem' will have their charges completely written off, not just the charge amount over the per diem amount).
  • Admission:
  • Two test clients are admitted to outpatient programs.
  • Financial Eligibility:
  • Assign contract guarantor to the test client.
  • Make sure there is a per diem rate defined for the benefit plan and the benefit plan covers the service codes from above step (Insurance Charge Category).
  • Client Charge Input:
  • Rendered 6 services for the test clients in the same month.
  • Client Ledger:
  • Verify all the charges distributed to the contract guarantor identified above.
  • Quick Billing Rule Definition:
  • At least two quick billing rules defined in the system.
  • Quick Billing Group Definition:
  • A group definition is created that includes the quick billing rules defined above.
  • The 'Add Rule Group To Scheduler' is set to "Yes".
  • The 'Claim From Date For Scheduled Batch' and 'Claim Through Date' are populated correctly.
  • Select the following tasks in 'Tasks to Execute': 'Create Batch', 'Close Charges', 'Generate Bills', 'Create Claims', and 'Post Contractual Adjustments'.
Steps
  1. Open the "System Task Scheduler" form:
  2. In the "Schedules" field, select the quick billing group definition task created in the 'Quick Billing Group Definition' from the list.
  3. Select a recurrence type pattern from the "Recurrence Pattern" field. For example "Daily".
  4. Populate the "Task Occurrence Sequence". For example "1".
  5. Populate the "Start by" field.
  6. Populate the "Start Time" field.
  7. Click [Schedule Task]
  8. Wait until after the date and time that the task is scheduled to execute.
  9. Open the 'Client Ledger' form:
  10. Select desired client.
  11. Select "All Episode" from the 'Claim/Episode/All Episode' field.
  12. Select "Simple" from the 'Ledger Type' field.
  13. Select desired date in the 'From Date' and 'To Date' fields to include the service date range for the client.
  14. Click [Process].
  15. Verify the services selected by the quick billing group task closed, claimed and the contractual adjustments are posted correctly.
Scenario 2: Quick Billing - Execute quick billing group rule - Validating 'Post Contractual Adjustments' for the Inpatient clients - After Client Merge
Specific Setup:
  • Service Codes:
  • Add or edit service codes that are defined as 'Per Diem' services. (Please note: Any inpatient services processed for Contractual Adjustment Posting that are not defined as 'Per Diem' will have their charges completely written off, not just the charge amount over the per diem amount). Note the 'Insurance Charge Category'.
  • Service Fee/Cross Reference Maintenance:
  • Service fees are created for the service codes.
  • Note: The fee must be greater than the per diem amount/percentage defined in the benefit plan.
  • Benefit Plan:
  • A per diem rate is defined for the benefit plan that is less than the Service Fee/Cross Reference Maintenance Fee.
  • Guarantors/Payors:
  • A guarantor is added or edited that it is defined as a 'Contract' guarantor in the 'Guarantor Nature' field.
  • The above 'Benefit Plan' is the default plan.
  • 'Contractual Guarantor Information' section:
  • 'Contractual Allowance By Batch' option is selected for the 'Does This Guarantor Use Contractual Allowance By Batch Or Through Liability Distribution' field.
  • Required fields are populated as desired.
  • Admission:
  • Two new test clients are admitted to inpatient and outpatient programs. The client admitted in the inpatient program will be used as a source client and the client admitted in the outpatient program will be used as a target client. Note the client ids.
  • Financial Eligibility:
  • Assign contract guarantor to the test clients' inpatient episodes.
  • Make sure there is a per diem rate defined for the benefit plan and the benefit plan covers the service codes from above step (Insurance Charge Category).
  • Client Charge Input:
  • Rendered services for the test clients in the inpatient programs in same month.
  • Client Ledger:
  • Verify all the charges distributed to the contract guarantor identified above.
  • Quick Billing Rule Definition:
  • Create a rule for the Non-contract guarantor and outpatient services. Note the rule description.
  • Create a rule for the contract guarantor and inpatient services. Note the rule description.
  • A group definition is created that includes the quick billing rules defined above.
  • Select 'No' in Add Rule Group To Scheduler'.
Steps
  1. Open the 'Client Merge' form.
  2. Select desired client as a source client.
  3. Select desired client as a target client.
  4. Populate all other required fields.
  5. Verify the source client merged in to the target client successfully.
  6. Open the 'Client Ledger' for the target client.
  7. Verify all the merged services distributed correctly to the correct guarantor.
  8. Open the ‘Quick Billing’ form.
  9. Set the field ‘Add New Or Edit Existing Quick Billing Batch’ to "Add New".
  10. Set the field ‘First Date Of Service To Include’ to desired date based on the services rendered to the client in the setup section.
  11. Set the field ‘Last Date Of Service To Include’ to desired date based on the services rendered to the client in the setup section.
  12. Set the field ‘Billing Rule Group To Execute’ to desired rule group created in the setup section.
  13. Verify that "Create Batch, Close Charges, Generate Bills, Create Claims, Post Contractual Adjustments" auto populated in the ‘Quick Billing Tasks To Execute’ field as these tasks are selected in the quick billing rule definition.
  14. Set the field ‘Date Of Claim’ to desired date.
  15. Submit the form.
  16. Verify the 'Compile Complete' message. The message also contains the quick billing batch number, Interim Billing Batch number and contractual adjustment posted notification.
  17. Click [OK].
  18. Click [NO] to 'Form Return' message.
  19. Open the 'Client Ledger' form.
  20. Select desired client.
  21. Select 'All Episode' from the 'Claim/Episode/All Episode' field.
  22. Select 'Simple' from the 'Ledger Type' field.
  23. Select desired date in the 'From Date' and 'To Date' fields to include the service date range for the client.
  24. Click [Process].
  25. Verify the services selected by the quick billing group closed, claimed and the contractual adjustments are posted.
Scenario 3: Contractual Allowance (Inpatient) - Post Contractual adjustments for the client - After Change MR#
Specific Setup:
  • Service Codes:
  • Add or edit service codes that are defined as 'Per Diem' services. (Please note: Any inpatient services processed for Contractual Adjustment Posting that are not defined as 'Per Diem' will have their charges completely written off, not just the charge amount over the per diem amount). Note the service code and 'Insurance Charge Category'.
  • Service Fee/Cross Reference Maintenance:
  • Service fees are created for the service codes.
  • Note: The fee must be greater than the deductible amount defined in the benefit plan.
  • Benefit Plan:
  • A per diem rate is defined for the benefit plan that is less than the Service Fee/Cross Reference Maintenance Fee.
  • Guarantors/Payors:
  • A guarantor is added or edited that it is defined as a 'Contract' guarantor in the 'Guarantor Nature' field.
  • The above 'Benefit Plan' is the default plan.
  • 'Contractual Guarantor Information' section:
  • 'Contractual Allowance By Batch' option is selected for the 'Does This Guarantor Use Contractual Allowance By Batch Or Through Liability Distribution' field.
  • Required fields are populated as desired.
  • Admission:
  • A test client is admitted to inpatient program. Note the client id.
  • Financial Eligibility:
  • Assign contract guarantor to the test clients' inpatient episodes.
  • Make sure there is a per diem rate defined for the benefit plan and the benefit plan covers the service codes from above step (Insurance Charge Category).
  • Client Charge Input:
  • Rendered services for the test clients using the service code identified above.
  • Client Ledger:
  • Verify all the charges distributed to the contract guarantor identified above.
Steps
  1. Open the 'Contractual Allowance (Inpatient)' form.
  2. Select 'Compile' for the 'Compile, View or Post' field.
  3. Enter the month and year for the services rendered to the client.
  4. Fill out the remaining required fields.
  5. Click [Process].
  6. Verify the services displayed correctly in the report with the expected contractual adjustments.
  7. Select 'View' from the 'Compile, View or Post' field.
  8. Click [Process].
  9. Verify the services to be posted displayed correctly in the report with the expected contractual adjustments.
  10. Open the 'Change MR#' form.
  11. Select a client set up in the setup section.
  12. Click [Assign MR#].
  13. Verify the 'New Client ID#' field contains different id than the previous one. Note the client id.
  14. Click [Submit].
  15. Verify the form submits successfully.
  16. Open the 'Contractual Allowance (Inpatient)' form.
  17. Select 'Post' from the 'Compile, View or Post' field.
  18. Set the 'Month/Year To Run Report For' field to desired month and year such that it covers the services for the client.
  19. Enter the 'Posting Date'.
  20. Select all other required fields.
  21. Click [Process].
  22. Verify the services posted displayed correctly in the report with the expected contractual adjustments for the new client.
  23. Open 'Client Ledger' form.
  24. Verify the contractual adjustments are correctly posted for the services that are included in the batch.
  25. Close the form.
Scenario 4: Contractual Allowance (Inpatient) - Post Contractual adjustments for the client - After 'Client Delete'
Specific Setup:
  • Service Codes:
  • Add or edit service codes that are defined as 'Per Diem' services. (Please note: Any inpatient services processed for Contractual Adjustment Posting that are not defined as 'Per Diem' will have their charges completely written off, not just the charge amount over the per diem amount). Note the service code and 'Insurance Charge Category'.
  • Service Fee/Cross Reference Maintenance:
  • Service fees are created for the service codes.
  • Note: The fee must be greater than the deductible amount defined in the benefit plan.
  • Benefit Plan:
  • A per diem rate is defined for the benefit plan that is less than the Service Fee/Cross Reference Maintenance Fee.
  • Guarantors/Payors:
  • A guarantor is added or edited that it is defined as a 'Contract' guarantor in the 'Guarantor Nature' field.
  • The above 'Benefit Plan' is the default plan.
  • 'Contractual Guarantor Information' section:
  • 'Contractual Allowance By Batch' option is selected for the 'Does This Guarantor Use Contractual Allowance By Batch Or Through Liability Distribution' field.
  • Required fields are populated as desired.
  • Admission:
  • 1-2 test clients are admitted to inpatient program. Note the client ids.
  • Financial Eligibility:
  • Assign contract guarantor to the test clients' inpatient episodes.
  • Make sure there is a per diem rate defined for the benefit plan and the benefit plan covers the service codes from above step (Insurance Charge Category).
  • Client Charge Input:
  • Rendered services for the test clients using the service code identified above.
  • Client Ledger:
  • Verify all the charges distributed to the contract guarantor identified above.
Steps
  1. Open the 'Contractual Allowance (Inpatient)' form.
  2. Select 'Compile' for the 'Compile, View or Post' field.
  3. Enter the month and year for the services rendered to the client.
  4. Fill out the remaining required fields.
  5. Click [Process].
  6. Verify the services displayed correctly in the report with the expected contractual adjustments.
  7. Select 'View' from the 'Compile, View or Post' field.
  8. Click [Process].
  9. Verify the services to be posted displayed correctly in the report with the expected contractual adjustments.
  10. Delete all the services rendered to the client.
  11. Delete all the movements using 'Delete Last Movement' form.
  12. Open the 'Client Delete' form.
  13. Delete the client.
  14. Open the 'Contractual Allowance (Inpatient)' form.
  15. Select 'Post' from the 'Compile, View or Post' field.
  16. Set the 'Month/Year To Run Report For' field to desired month and year such that it covers the services for the client.
  17. Enter the 'Posting Date'.
  18. Select all other required fields.
  19. Click [Process].
  20. Verify the services posted displayed correctly in the report with the expected contractual adjustments for the new client.
  21. Open 'Client Ledger' form.
  22. Verify the contractual adjustments are correctly posted for the services that are included in the batch and the deleted client is not included in the posting.
  23. Close the form.
Topics
• Contractual Allowance (Inpatient) • Contractual Allowance (Outpatient) • NX • Quick Billing • System Task Scheduler
AV-88139 Summary | Details
Functional Or Implementation Acknowledgement (997/999) - Compiling the 999 file created from the 270 file
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Crystal Report Viewer
  • Eligibility Inquiry (270) Request
  • Eligibility Inquiry (270) Submission
  • Functional or Implementation Acknowledgement (997/999)
Scenario 1: Functional or Implementation Acknowledgement (997/999) - Validating data retrieved after loading/compiling file
Specific Setup:
  • The 'Avatar PM > Billing > Electronic Billing > All 837 Submissions > Maintain Unique Functional Group Control Numbers By Root System Code' registry setting is set to "Y".
  • Eligibility Inquiry (270) Submission:
  • Compile a 270 transaction for a guarantor that is configured for 270 submissions.
  • Create/Update the included 999 file such that the values from GS-06 and ST-02 fields of the 270 file is included in the AK1-02 and AK2-02 fields of the 999 file.
  • GS-06 (270) --> AK1-02 (999)
  • ST-02 (270) --> AK2-02 (999)
Steps
  1. Open the 'Functional or Implementation Acknowledgement (997/999)' form.
  2. Load/ Compile the 999 file.
  3. Verify the file loads successfully.
  4. Compile the recently loaded file.
  5. Verify the file compiles successfully.
Topics
• Functional or Implementation Acknowledgement (997/999) • NX
AV-88150 Summary | Details
Eligibility Inquiry 270 Request - Delete inquiry
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Eligibility Inquiry (270) Request
  • Guarantors/Payors
Scenario 1: Eligibility Inquiry (270) Request - Add / Delete 'Generic' and 'Specific' inquiry
Specific Setup:
  • Guarantors/Payors:
  • An existing guarantor is identified to be used. Note the guarantors code/name.
  • Service codes:
  • An existing service code is identified to be used. Note the service code/description.
  • Service Fee/ Cross Reference Maintenance:
  • A fee definition is created for the service code identified in the ' Service Codes' form.
  • Admission:
  • An existing client is identified, or a new client is admitted. Note client id, admission program, admission date.
  • Financial Eligibility:
  • A guarantor identified in the 'Guarantors/Payors' form is assigned to the client as a primary guarantor.
  • Client Charge Input:
  • A service is rendered to the client. Note service date, service code.
  • Client Ledger:
  • A service distributed correctly to the assigned guarantor.
Steps
  1. Open the 'Eligibility Inquiry (270) Request' form.
  2. Create a generic request for a client and a guarantor.
  3. Make sure to use the same client/guarantor.
  4. Click [Select Pending Inquiry].
  5. Select the inquiry which is added in above steps.
  6. Click [Delete Inquiry].
  7. Review the pending inquiry again.
  8. Verify that the selected inquiry is deleted.
Topics
• Eligibility Inquiry (270) Request • NX
AV-88898 Summary | Details
Service/Fee Cross Reference - CPT-4 / HCPCS Modifier If Not First Instance For Service Date
Note - These testing guidelines assume the user is skilled in the use of, at a minimum, the following:
  • Admission (Outpatient)
  • Client Charge Input
  • Client Ledger
  • Create Interim Billing Batch File
  • Diagnosis
  • Electronic Billing
  • Financial Eligibility
  • Guarantors/Payors
  • Individual Cash Posting (PM)
  • Registry Settings (PM)
  • Service Codes
  • Service Fee/Cross Reference Maintenance
Scenario 1: 837 Professional - Validating the 'CPT-4 / HCPCS Modifier' and 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date'
Specific Setup:
  • Registry Settings:
  • The 'Include CPT-4 Modifier If Not First Instance For Service Date' registry setting is set to 'Y'.
  • Service Codes:
  • A professional service code is identified. Note the service code.
  • Service Fee/Cross Reference Maintenance:
  • The 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date' field is populated with the two digit value for the service code. Note the value of the field.
  • Guarantors/Payors:
  • Two existing guarantors are identified to be used. Note the guarantor codes/names. Note the Guarantor name and ID.
  • Admission:
  • An existing outpatient client is identified, or a new client is admitted to the outpatient program. Note the client id.
  • Financial Eligibility:
  • The guarantors identified in the 'Guarantors/Payors' form are assigned to the client as a primary and secondary guarantor.
  • Diagnosis:
  • A diagnosis record is created for the client.
  • Client Charge Input:
  • 4-5 service(es) are rendered to the client. Note the service code and date of service.
  • Client Ledger:
  • Verify the service(es) distributed correctly to the primary guarantor assigned to the client.
  • Close the charges.
  • Create Interim Billing Batch:
  • An Interim billing batch is created that covers client, service(es) and the guarantor.
Steps
  1. Open the 'Electronic Billing' form.
  2. Compile the 837 Professional bill for the interim billing batch created in the setup section.
  3. Verify the file compiles successfully.
  4. Review the 837 file dump file.
  5. Locate the 2400-SV1 segment.
  6. Verify the SV1 segment does not include modifier from the 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date' field and it includes modifier from the 'CPT-4 / HCPCS Modifier' field.
  7. Verify the SV1 segment includes the modifier from the 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date' field for all the instances of the service code after the first instance of the service code.
  8. Open the 'Individual Cash Posting' form.
  9. Transfer the service from the primary guarantor to secondary guarantor.
  10. Submit the form.
  11. Open the 'Client Ledger' form.
  12. Verify the service correctly transferred to the secondary guarantor.
  13. Close the form.
  14. Open the 'Individual Cash Posting' form.
  15. Transfer all the service(es) from the secondary guarantor to the primary guarantor.
  16. Submit the form.
  17. Open the 'Client Ledger' form.
  18. Verify the service correctly transferred back to the secondary guarantor.
  19. Close the form.
  20. Open the 'Electronic Billing' form.
  21. Compile the 837 Professional bill again for the primary guarantor.
  22. Verify the bill compiles successfully.
  23. Review the 837 file dump file.
  24. Locate the 2400-SV1 segment.
  25. Verify the SV1 segment does not include modifier from the 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date' field and it includes modifier from the 'CPT-4 / HCPCS Modifier' field.
  26. Verify the SV1 segment includes the modifier from the 'CPT-4 / HCPCS Modifier If Not First Instance For Service Date' field for all the instances of the service code after the first instance of the service code.
  27. Close the form.
Topics
• 837 Professional • NX