Add/Update Policy Details

Tip: You can view the results of all eligibility checks run for prior dates of service for the patient's insurance package using the Eligibility History tab on the Payer-Provided Eligibility Details page.

1. Display the Update Policy Details page: On the Quickview, under the Insurances heading, click Update this policy.
   At the top of the page, you can see the patient's current eligibility status and the date that the status was last checked.
2. Scroll down to the Eligibility area.
3. Take action on eligibility status — Click the Check at prior date of service option.
   The Date of service field appears.
   Note: Some payers do not support eligibility checks for prior dates of service.
4. Date of service — Select one of the patient's previous dates of service. You can select a date of service for which there is an open claim or a date of service with no open claims.

5. Click Update & Perform Eligibility Check.
   The results of the eligibility check appear.
   

    

   Important: When you manually check eligibility, wait 20 seconds for a response from the payer (or an error message) before you attempt to check eligibility again.

1. On the Quickview, under the Insurances heading, click add new.
   The Add Policy page appears with the Standard policies option selected by default.
2. Search for and select the policy name in the insurance packages list. (For detailed information about locating the correct package, see Add Policy.)
   The Add Policy Details page appears.

Policy Information

3. Patient's relationship to policy holder — Select the patient's relationship to the policy holder. If you select "Self," athenaOne auto-fills several of the policy-holder fields.
4. Member ID/certification number — Enter the patient's member ID number from the patient's insurance card.
   (This field populates box 1a on the CMS-1500 form.)
5. Policy/group number — Enter the patient's group number from the insurance card.
6. Issue date — Enter or select the issue date of the policy.
7. Expiration — Enter or select the expiration date of the policy.
8. Copay amounts — This field defaults to Office Visit. Enter the copay amount for an office visit in the $ field to the right of the menu. This amount appears on the Check-in and Checkout pages when you collect patient payments.
   Note: If you leave the Copay amounts field blank, athenaOne may auto-populate the Office Visit copay amount from the eligibility message from the payer.
9. To add another copay amount:
1. Click the Add another copay amount link.
   Another copay field appears.
2. Select the copay type from the menu and enter the copay amount.

Note: athenahealth recommends that you update patient insurance policies to include up-to-date insurance copay types and amounts.

 

10. Coinsurance percentage — Enter the coinsurance percentage. This value appears on the Check-in and Checkout pages when you collect patient payments.
    Note: If your practice has the payer's allowable schedule in athenaOne and the procedure code is included in the allowable schedule, the expected coinsurance amount is 20% of the allowable.
    If the payer's allowable schedule is not in athenaOne (or if the allowable schedule lacks the procedure code), the expected coinsurance amount is 20% of the charge amount from the fee schedule.
11. Referring provider — Click Choose/view, then search for and select the provider who referred the patient. This provider will be the default referring provider on all claims.
    Note: If you add or update a referring provider to a patient's insurance, you can update all existing appointments and admissions associated with that insurance.
12. Primary care provider — Click Choose/view, then search for and select the patient's primary care physician.
13. Default Medicare secondary qualifier — This field appears only when you add a Medicare policy. The menu provides reasons why Medicare is the secondary payer (if applicable). The resulting code is included on the claim that goes to Medicare, so that the claim is paid correctly. This information may be needed when submitting Medicare Secondary Payer (MSP) claims. For more information, see the Medicare as a Secondary Payer Questionnaire page.
    
14. Notes — Enter any notes about this policy for this patient. You can use this field to record deductible information, the customer service phone number, and other relevant information.

Policy Holder

15. Entity type — Select the policy holder's entity type.
16. Policy holder ID/certification number — If the Patient's relationship to policy holder is set to "Self," this field auto-populates with the number in the Member ID/certification number field.
    If the Patient's relationship to policy holder is not "Self," enter the policy holder's policy ID number.
17. Last name — Enter the policy holder's last name if the policy holder is a person. Enter the name of the entity if the policy holder is not a person.
18. First name — Enter the policy holder's first name if the policy holder is a person. Leave blank for non-person entity.
19. Middle name, suffix — Enter the policy holder's middle name and name suffix if any). Leave blank for non-person entity.
20. Address — Enter the first line of the policy holder's address.
21. Address (ctd) — Enter the second line of the policy holder's address (if needed).
22. ZIP — Enter the policy holder's 5-digit ZIP code. After you enter the ZIP code, the city and state are auto-populated from the athenahealth ZIP code database.
23. Country — Enter the policy holder's country. (This field appears only if your practice has the "Foreign Patient Addresses" feature enabled.)
24. SSN — Enter the policy holder's Social Security number.
    Note: Practice staff registering patients for the first time or editing registration information can enter or re-enter SSN numbers. To see the full Social Security number after it is entered, you must have the Display Full SSN user permission.
25. DOB — Enter the policy holder's date of birth.
26. Sex — Select the policy-holder's gender. If the policy-holder is a non-person entity, select the patient's gender. This field is labeled Patient Sex if the policy-holder is a non-person entity.
27. Employer — Click the Choose link to access the Employer Lookup tool and select the name of the policy holder's employer (or school, if the policy holder is a student). This name is printed in CMS-1500 field 11, labeled "Employer's name or school name."
    Note: If the patient's registration information includes an employer, and if the patient's relationship to insured is SELF, the Employer field defaults to the value in the Patient Registration Employer field. If you select an alternate employer here, athenaOne does not automatically update the patient's registration information.
    
28. Click Add Policy or Add Policy & Perform Eligibility Check.
    You may get a message box saying: "There are open claims for this patient which may need to be changed. Do you want to see them now?" Click Yes to display the View Claim History page, or click No to return to the Quickview. The policy and eligibility status message appear on the Quickview page under the "Insurances" section.

Fields updated when you perform an eligibility check

When you click Add Policy & Perform Eligibility Check or Update Policy & Perform Eligibility Check, athenaOne overwrites the data on the Payer-Provided Eligibility Details page and in the following fields (even if the result is Unverified).

Fields on the Quickview and Check-in pages

• Status
• Status Reason
• PCP
• Inquiry Date
• Message
• Plan Description

Fields on the Add / Update Policy Details page:

• Eligibility status
• Last inquiry
• Last eligibility message

1. On the Quickview, under the Insurances heading, click add new. Select the policy name from the insurance packages list.

Policy Information

2. Patient's relationship to policy holder — Select the patient's relationship to the policy holder. If you select "Self," athenaOne auto-fills several of the policy-holder fields.
3. Member ID/certification number — Enter the patient's member ID number from the patient's insurance card.
   
   (This populates box 1a on the CMS-1500 form.)

Policy Holder

4. Entity type — Select the policy holder's entity type.
5. Policy holder ID/certification number — If the Patient's relationship to policy holder field is set to "Self," this field auto-populates with the number in the Member ID/certification number field.
   If the Patient's relationship to policy holder is not "Self," enter the policy holder's policy ID number.
6. Last name — Enter the policy holder's last name if the policy holder is a person. Enter the name of the entity if the policy holder is not a person.
7. First name — Enter the policy holder's first name if the policy holder is a person. Leave blank for non-person entity.
8. Middle name, suffix — Enter the policy holder's middle name and name suffix if any). Leave blank for non-person entity.
9. Address — Enter the first line of the policy holder's address.
10. Address (ctd) — Enter the second line of the policy holder's address (if needed).
11. ZIP — Enter the policy holder's 5-digit ZIP code. When you enter the ZIP code, the city and state are auto-populated from the athenahealth ZIP code database.
12. Country — Enter the policy holder's country. (This field appears only if your practice has the "Foreign Patient Addresses" feature enabled.)
13. SSN — Enter the policy holder's Social Security number.
    Note: Practice staff registering patients for the first time or editing registration information can enter SSNs, and can re-enter SSNs. To see the full Social Security number after it is entered, you must have the Display Full SSN user permission.
14. DOB — Enter the policy holder's date of birth.
15. Sex — Select the policy-holder's gender. If the policy-holder is a non-person entity, select the patient's gender. This field is labeled Patient sex if the policy-holder is a non-person entity.
16. Employer — Click the Choose link to access the Employer Lookup tool and select the name of the policy holder's employer (or school, if the policy holder is a student). This name is printed in CMS-1500 field 11, labeled "Employer's name or school name."
    Note: If the patient's registration information includes an employer, and if the patient's relationship to insured is SELF, the Employer field defaults to the value in the Patient Registration Employer field. If you select an alternate employer here, athenaOne does not automatically update the patient's registration information.
17. Click Add Policy.

Note: If your practice uses athenaClinicals without the athenaCollector service, some functions are not available, and some fields, columns, buttons, and links may not appear.

1. On the Quickview, under the Insurances heading, click Update this policy.
2. Edit fields as needed.
3. Click Update Policy or Update & Perform Eligibility Check.
   A message may appear, stating: "There are open claims for this patient which may need to be changed. Do you want to see them now?" Click Yes to display the View Claim History page, or click No to return to the Quickview. The Policy History section (at the bottom of this page) reflects the updates you made.
   Note: If electronic eligibility is not available for this package, the Update & Perform Eligibility Check button is disabled.

Updates to demographic information and insurance policies

If you update the Address, ZIP code, City, State, SSN, DOB, or Sex fields on the Quickview or Patient Registration page, athenaOne automatically updates all insurance policies (where the patient relationship to insured is Self) with the new information.

athenaOne does not automatically update the policy-holder's name because some payers require that the policy holder name on the claim appear exactly as it does in the payer's system. Therefore, if you make a change to the patient's name (last name, first name, middle name, suffix), a warning message appears:
"There are insurance policies for this patient that may need to be updated. Click "update this policy" from the Quickview page to make changes".

If this warning message appears, click OK, review the information in the insurance policy to ensure that it is correct, and make changes if necessary.

Fields updated when you perform an eligibility check

When you click Add Policy & Perform Eligibility Check or Update Policy & Perform Eligibility Check, athenaOne overwrites the data on the Payer-Provided Eligibility Details page and in the following fields (even if the result is Unverified).

Fields on the Quickview and Check-in pages

• Status
• Status Reason
• PCP
• Inquiry Date
• Message
• Plan Description

Fields on the Add / Update Policy Details page:

• Eligibility status
• Last inquiry
• Last eligibility message

1. Display a patient's Quickview page: In the text box at the top right of the Main Menu, enter the first three letters of the patient's last name, followed by a comma, followed by the first three letters of the patient's first name. Click the search icon. On the Find a Patient page, click Quickview for the patient you need.
3. Click Update this policy (under Insurances).
   The Add/Update Policy Details page appears.
4. Click Update & Perform Eligibility Check.
   The Payer-Provided Eligibility Details page appears.
5. Click View Policy.
   
   The Expiration date on the policy is updated, if applicable.

After you make a manual update to the information on the Add/Update Policy Details page and save, the View eligibility detail and history link remains available on the Quickview page.

Manually setting a patient's member ID number

 

Payers sometimes return an incorrect patient member ID number, which overwrites the ID number in the patient's policy in athenaOne. To prevent a patient's member ID number from being overwritten by the eligibility response, you can manually set the member ID number on the Update Policy Details page.

1. Display the Update Policy Details page: On the Quickview, under the Insurances heading, click Update this policy.
2. Enter the member ID number in the Member ID/certification number field.
3. Scroll down to the Eligibility area.
4. Take action on eligibility status — Select the Override payer-returned result option.
   The New status and New reason fields appear.
   
5. New status — Select the eligibility status.
6. New reason — Select the reason for your update.
7. Click Update Policy.

Note: This procedure can also be used to manually set the patient's eligibility status to Eligible or Ineligible.

 

A patient's Medicare suffix can change from time to time due to a change in circumstances. For example, when a patient who was previously covered under a spouse's policy reaches age 65 and receives his/her own policy, the patient's suffix changes as well. This change can happen without the patient's knowledge. If this occurs, an old Medicare member ID image may still be on file with your practice.

When an eligibility request is sent to Medicare, the response shows the most recent member ID that Medicare has on file for the patient. If the old member ID is sent in the eligibility transaction, an "Unverified" eligibility status is returned.

To address this issue, athenaOne will resend these unverified responses with the new member ID and fetch an eligible response from the payer; athenaOne then update the patient's policy with the updated member ID automatically. The updated member ID is the one that should be used to bill the claim.

Note: There is a short time lapse in which an unverified response will be seen before the new eligibility check is automatically sent.

Patient validation messages alert you to potential billing or workflow issues. Validation messages appear on these pages: Quickview, Check-in, Update Policy Details, Appointment, and Schedule Appointment. By addressing these issues, you reduce work for your billing staff and increase the probability of successful claim adjudication. These issues include:

• Demographic mismatches
• Missing patient demographic data
• Missing insurance card images
• Insurance package review issues
• Coordination of benefits issues

Note: Primary insurance is checked on the Quickview, Check-in, Update Policy Details, Appointment, and Schedule Appointment pages. Secondary insurance is checked only on the Update Policy Details page.

These validation checks are based on rules from the athenahealth billing rules engine and the patient rules engine. If a patient validation rule is triggered, a message indicating the potential issue appears on one or more of these pages.

• A red warning message alerts you to issues that will cause the patient's claim to go into HOLD or MGRHOLD.
• A purple informational message indicates issues that you should be aware of but that may not hold the claim.

To ignore a warning message, click Dismiss in the warning message. To reduce the likelihood of claims being sent to your HOLD and MGRHOLD queues, correct these issues before claim creation.

Patient Validation Rules report

 

The Patient Validation Rules report provides visibility into staff behavior and creates training opportunities for your practice. This report, which you can find on the Front Office Operations tab of the Report Library, displays the following information:

• For each user and each rule, the number of times that the user dismissed the rule at check-in.
• Number of claims created in HOLD with that rule.

athenaOne sends out-of-state BCBS claims to the correct processing center automatically, per the guidelines of the BlueCard program.

Although the BlueCard program instructs providers to submit claims to their local BCBS office, athenaOne requires that you register the patient using the plan listed on the patient's insurance card (referred to as the "home plan"), even if that plan is outside the state where services are rendered. athenaOne must identify the correct "home plan" in order to apply claim routing rules correctly.

For example, if a Massachusetts provider renders service in Massachusetts, but the patient's "home plan" is through BCBS Illinois, the Massachusetts provider must register the patient with a BCBS IL insurance policy. After the policy is registered and a claim is generated, claim rules flip the selected "home plan" insurance package on the claim to the appropriate "local plan" to fulfill BlueCard routing requirements. This flip on the back end ensures that all claims are submitted to the appropriate office.

Note: For more information, see BCBS Claim Routing and Special Handling.

Current laws and regulations require that all entities billing Medicare for services or items rendered to Medicare beneficiaries must determine whether Medicare is the primary or secondary payer for those services or items.

To meet this requirement, you can use the Medicare as a Secondary Payer Questionnaire in athenaOne. This eliminates paperwork and provides an audit trail showing who administered the questionnaire, when the information was gathered, and what data was captured.

To determine whether Medicare qualifies as a patient's secondary payer

 

Note: If you choose to use your current Medicare as a Secondary Payer Questionnaire workflow outside of athenaOne, you can still set the qualifier manually and ignore the Complete MSP questionnaire link.

1. For a patient on Medicare, start the Check-in stage of an appointment.
2. Medicare secondary qualifier — Click Complete MSP questionnaire to display the Medicare as a Secondary Payer Questionnaire page.
3. On the Medicare as a Secondary Payer Questionnaire page, select all options that apply to this patient.
   As you click the relevant options, some of the statements and questions expand to display additional related options.
4. Complete each field per the instructions on the page.
5. Select who is answering the questionnaire (usually this is Self, meaning the patient).
6. Proceed through each question until prompted to save your answers.
7. Click Save.
8. The Check-in page reappears.
9. Medicare secondary qualifier — Select the qualifier, if necessary.
   Note: If the appointment is part of a treatment series, check the Appointment is part of a treatment series box. If you check this box, you can select the appointment with a completed MSPQ that should be associated with the ongoing series. The menu is populated with all appointments and relevant qualifiers completed within the past 90 days.
   

You can access the appointment audit on the View Patient Appointments page by clicking Audit history next to the MSPQ completed note.

 

When a claim appears to have been paid below or above the expected allowed amount, you can review the claim and see that it was priced by an unexpected allowable schedule.

For example, if you determine that the HMO allowable schedule should have priced the charge, instead of the PPO allowable schedule, you can easily change the product type, so that the proper allowable schedule is pricing the claim.

To correct the policy's Pricing product type:

1. Display the patient Quickview: In the text box at the top right of the Main Menu, enter the first three letters of the patient's last name, followed by a comma, followed by the first three letters of the patient's first name. Click the search icon. On the Find a Patient page, click Quickview for the patient you need.
2. In the Insurances section, click Update this policy for the relevant insurance policy. The Update Policy Details page appears.
3. On the Update Policy Details page, select the correct product type from the Pricing product type list.
4. Click Update Policy.

To see the result of changing the Pricing product type, you have three options:

• Open the Claim Edit page for the claim that you are researching and click Save Claim. On the Claim Review page, click edit claim to return to the Claim Edit page. This operation reprices the charge according to the allowable schedule for the pricing product type you selected.
• If the claim is in the reporting range you select on the Payment Mismatch Tracking report, athenaOne prompts you to reprice it, along with the other out-of-date claims in the Payment Mismatch Tracking report results.
• Wait for athenaOne to automatically reprice the claim overnight.

Note:

• This change updates only this specific patient's Pricing product type; this change does not update the insurance package itself.
• If the patient has several claims, this change applies to all claims created under this policy.
• The policy dates are still in effect, so the Pricing product type does not apply to any of the patient's prior policies.

Our posting policy follows the Florida MVA 80/20 rule. Florida MVA insurance regulations state that there is an 80/20 split on the state-defined allowable amounts in relation to services rendered for an MVA injury—80% of the allowed amount being paid by the insurance carrier, and the remaining 20% being the responsibility of the patient. Any amount in excess of the state-defined allowable amount will be posted as a contractual adjustment.

Note: Only the following states have defined MVA allowable schedules:

• Florida
• New Jersey
• New York
• Oregon
• Pennsylvania

athenaOne has imported state-defined MVA allowable schedules for:

• Florida
• New Jersey
• Oregon

athenaOne has imported state-defined WC allowable schedules for:

• Florida
• Texas