BLUE REVIEW^SM

October 2023

Avalon Healthcare Solutions - Trial Claim Advice User Guide

1.0 About Trial Claim Advice

Health plans work with Avalon Healthcare Solutions to administer a comprehensive suite of laboratory benefit management services. Avalon is an independent company that provides benefit management services on behalf of our payer clients.

The Trial Claim Advice does not incorporate benefit coverage, eligibility or other claim edits by the health plan. Therefore, the advice shown through Trial Claim Advice only reflects the compliance with health plan payment policies.

The results of this tool are not a guarantee of how an actual claim may adjudicate. Trial Claim is for simulation purposes only and not a guarantee of how an actual claim may adjudicate.


1.1 Logging into Trial Claim Advice

The Trial Claim Advice tool can be accessed on Avalon’s provider portal through Availity at the following Availity.com/Essentials. Clicking on the link in Availity opens the Avalon Provider Portal. The Trial Claim Advice tool can be accessed by clicking on the Trial Claim Advice button. Please contact Avalon Provider Services at 1-855-895-1676 if you have questions regarding the Trial Claim Advice tool.

1. Select Application Pages.
2. Select Trial Claim Advice.
3. Select Trial Claim Advice.

When the Trial Claim Entry page loads initially, a Disclaimer is displayed. You must agree to the Disclaimer Message by clicking the YES, I AGREE button in order to proceed with Trial Claim entry.

Note: If you click the Cancel button, the user returns to the Avalon Portal homepage.

Select YES, I AGREE.

 4. Select BCBS plan from the drop-down list.

1.2 Entering a Trial Claim

Trial Claim Advice tool offers two options for submitting a Trial Claim: without specific member information or with member information.
Trial Claim Advice defaults to evaluation without membership. Avalon recommends providing membership information for all Trial Claims. The specific member information enables a more complete evaluation of the Trial Claim information and Health Plan policies.

Enter the full ID number format [alpha-numeric prefix + 12 digit ID Number (you must include leading 0s after the prefix to = 15 characters total in length; example 1: ID card lists ID Number as YUP123456789]; when inputting ID, you will include 000 after the prefix, i.e. YUP000123456789, Patient First Name, Last Name, and Gender. Example 2: ID card lists ID Number as YUP1234567891]; when inputting ID Number, you will include 00 after the prefix, i.e. YUP001234567891, Patient First Name, Last Name, and Gender. You must input ID Number as 15 digits to return historical claims finalized through the previous business day.

Required fields are indicated with an asterisk (*).

1.3 Provider Information

1. Enter the patient’s age in the Age field. Press Tab to go to the next field.
2. Select the patient’s gender from the Gender drop-down list. Press Tab to go to the next field.
3. Enter Billing Provider NPI. Press Tab to go to the next field.
4. Enter Rendering Provider NPI. Press Tab to go to the next field.

1.4 Diagnosis Codes Section

The Diagnosis Code section mimics the Header level documentation of diagnosis codes. The claim line section in 2.1.E below permits the assignment of diagnosis codes to an individual claim line. In order for a claim line assignment of a diagnosis code to occur, the diagnosis code must be documented in the Diagnosis Code Section. At least one diagnosis code is required and up to 24 Diagnosis Codes may be entered.

1. Enter a valid diagnosis code. Press Tab.
   The description for the diagnosis code entered is displayed in the Description field.
   Note: The Description field is a read only display field, and does not require any user input.


2. To enter additional diagnosis codes, click the +Add Diagnosis Code link. A new row is added for entering another diagnosis code.


3. To delete any individual row, click delete icon from the Action column.
   Note: To replace the diagnosis code entered in the 1st row, type over the existing data, and press Tab.

1.5 Claim Lines section

This section allows up to 999 claim lines to be entered. At least one line must be completed.

1. Enter the Date of Service in MM/DD/YYYY format, or select from the Calendar view. And, press Tab to go to the next field.
2. Enter a valid Procedure Code, and press Tab. The description for the Procedure Code entered displays in the Description field. Press Tab again to go to the next field.
   Note: Description field is a read only display field, and does not require any user input.


3. Enter a valid Procedure Code modifier in Proc Mod field. You can enter up to four Procedure Code Modifiers. Press Tab to go to the next field.
   Note: Procedure Code modifiers must be unique across the four fields and cannot be a duplicated.


4. Select a Place of Service (POS) from the dropdown, and press Tab to go to the next field.
               • POS 81 – Independent Laboratory
               • POS 11 – Physician Office
               • POS 19 – On Campus-Outpatient Hospital
               • POS 22 – Off Campus-Outpatient Hospital


5. Select a Primary Diagnosis Code from the dropdown. Press Tab to go to the next field.
   Note: The dropdown ONLY displays the lists of Diagnosis Codes entered in the Diagnosis Code field above. A Primary Diagnosis Code is required for each claim line.


6. Select the Related Diagnosis Code(s) from the dropdown. Press Tab to go to the next field. Related Diagnosis Codes are optional.
   Note: The dropdown ONLY displays the lists of diagnosis codes entered in the Diagnosis Code section above.


7. Enter the number of Units associated with the procedure. Press Tab.


8. To enter additional claim lines, click the +Add Claim Line link. A new row is added to enter another claim line. To delete any individual row, click delete icon from Action column.
   Note: To replace data entered in the 1st row, type over the existing data, and press Tab.


9. Click Submit Claim button to process the information as a Trial Claim.
   Note: Clicking the Cancel button causes the user to return to the Avalon Portal homepage.

2.0 Trial Claim Result Section

Once the claim is successfully processed, the results are displayed. Clicking on the Trial Claim Entry Detail bar toggles presentation of the information entered for the Trial Claim.
Similarly, clicking on the Trial Claim Results bar toggles the results. Clicking on the cancel button returns to the Avalon Portal Home Page.

After the Trial Claim is processed successfully, these fields display in the Results section:

• +/- Symbol: Click on this symbol to expand/collapse the Decision lines if more than one decision returned for the claim line.
• # : This column indicates the claim line number.
• Procedure Code: This column displays the Procedure Code entered.
• Decision Type: This column displays the Decision Type for the claim, and displays only for the first decision line of the claim line. (Click the + button to see additional decisions for this code)
• Decision Rank: This column displays the ranking of multiple decisions for a claim line. For each procedure or claim line, multiple decisions could be returned.
• Decision Description: This column displays the descriptive explanation of the decision – see below for a list of decision descriptions.
• Policy Name: This section displays BCBS policy name.
• Edit Description: This section displays the Denial Edit Description.
• Clinical Payment and Coding Policy (CPCP) Tag: This section displays the BCBS policy number. The policies can be accessed at https://www.bcbsok.com/provider/standards/standards-requirements/cpcp/avalon
• Requested Units: This section displays the Requested Units.
• Approved Units: This section displays ONLY the Approved Units based on policy comparison.
• Pay and Educate: This section displays if this policy rule is currently in the Pay and Educate stage of the education process.

3.0 Examples of Decision Descriptions

• No Avalon Claim Editor advice was rendered
• Experimental and Investigational Procedure
• Insufficient time between procedures
• Maximum allowable units was exceeded
• Procedure is inappropriate for patient age
• Procedure is inappropriate for patient gender
• Procedure is allowed once per lifetime
• Procedure was performed at an incorrect Place of Service
• Procedure cannot be performed with another procedure
• Procedure was not appropriate for the clinical situation
• Too many procedures in one day
• Too many procedures within the required period of time

Unlisted Code, No Avalon Claim Editor advice was rendered

4.0 Examples of Edit Descriptions

• Not Valid with other Procedures on DOS
• Required Procedure not Found on DOS
• Dx Code not Allowed
• Required Dx Code not Found
• Procedure Not Allowed
• Allowed Dx Code

If you have additional questions, please contact: Avalon Provider Services at 1-855-895-1676.