Quick Reference — To correct BAC claims

1. Determine whether the patient information on the EOB matches the information on the Update Policy Details page and on the patient's insurance card.
2. Check the patient demographic information.
   1. If a scanned image of the patient's ID card is present in the policy registration in athenaOne, open it
   2. If patient ID cards are not scanned into athenaOne, refer to the patient record on site.
   3. Please contact the patient if there is not copy of the insurance ID available

3. Compare the patient name and ID number on the Update Policy Details page, Quickview and EOB to the information on the card. If it varies, contact the patient and correct the information on the Update Policy Details and Quickview pages.

1. Advise the patient to call the contact person for the insurance policy – employed, payer, social worker (if Medicaid), or Social Security office (for Medicare) – to correct the information on file so that claims can be processed
2. Make sure to correct demographic errors on both the Update Policy Details page and the Quickview
3. If changes are made to the insurance, athenaOne will prompt to determine whether this change should apply to all open claims or only the current claim. Select the appropriate option. Please review and resubmit all the claims for this patient.
4. After determining that the demographic information is correct, use the kick code DRPPATIENT to resubmit the claim. This kick code resubmits the claim with an internal note that patient information has been corrected/updated.

1. If the patient has other insurances registered – primary, secondary, tertiary, or case policy (carve-out) package – review the EOB notes carefully. Sometimes, it is clearly noted exactly who the other payer is.
2. Check the patient Quickview to see if the patient has any other insurance policies, and then determine if the insurance policies were registered in the wrong order. Click the "switch order" link to switch the primary and secondary policies, allowing the claim to be sent to the other insurance.
   
   To send the EOB from the original payer, print the EOB and attach the document to the claim using the Manage Attachments page.
3. For most payers, coverage is shown in the eligibility detail. This can be viewed by clicking the view details link under the policy in the patient's Quickview. For government payers such as Medicaid, if the payer's records show patient eligibility with some other payer to be primary, even if the patient is no longer eligible with that "primary" payer, the patient will need to contact the "secondary" payer (usually Medicaid) to update the coordination of benefits information.
   Note: Attaching an EOB from a commercial payer indicating that the patient was not eligible for the date of service seen is not sufficient to resolve a Medicaid BAC denial if that commercial payer is primary by Medicaid for that service date.
4. View the payer eligibility for the DOS in question on the Quickview by selecting history for the insurance package. If the claim DOS does not appear in the eligibility history, run an eligibility check.
   1. Return to the Quickview and select Update this policy.
   2. Scroll down to the Eligibility section and locate the Take action on eligibility status option.
   3. Click the Check at prior date of service option.
   4. Date of Service — Select the dates of service in question.

5. If another payer should be primary for this claim and that policy appears on the patient Quickview under the Case Policy section, use the Primary Payor menu on the Claim Edit page to select the case policy as the primary payer on the claim. If you want to send the EOB from the original payer that was billed, print the EOB and upload it into the claim in athenaOne using the Manage Attachments page.
6. If the claim is for a carve-out service and there is no case policy registered on the patient Quickview, contact the patient to determine who should be billed on the claim.
7. If the EOB states "This is not our patient" and the patient demographic information is correct, contact the patient to determine whether there are other benefits. It may be that the patient gave incorrect information at registration.
8. If it is determined that the patient is responsible for the claim, transfer the charges to the patient in one of two ways:
   1. Display the Claim Edit page and select "No Insurance/Self Pay" from the primary payer menu.
   2. Display the Claim Action page, and select Transfer Balance from the Actions menu.

Each practice has its own policies and procedures regarding billing patients on Medicare or Medicaid (including Medicaid-HMOs). Make sure to follow those policies and procedures when sending bills to patients.

For claims where the government payer cannot identify the patient as covered, bill the patient by using the PTRESP kick code to move the claim to the patient. Medicaid claims will be held in a MGRHOLD status (with the error MCAIDBAL for review of billing compliance via Medicaid billing.

When part of a claim has been paid, Medicaid and Medicare patients generally cannot be balance-billed without review by their physician's office. In exceptional cases where the patient responsibility is explicitly listed on the EOB, the patient can be billed, but only after efforts to resolve the claim without passing the charges on to the patient have been exhausted.

Note: At least one change must be made to the claim before it can be resubmitted. It is not compliant to resubmit a claim without changes only to see whether the claim will be paid if you resubmit it to the payer.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information.
3. Actions — If the claim needs to be resubmitted to the payer, select Add Kick Reason.
4. Make any necessary changes to the claim details.
5. Kick reason — Enter DRPBILLING.
6. Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
7. Click Submit.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information and existing documentation.
3. Actions — Select Resubmit to Payer from the menu.
   The Resubmission request page appears.
   Note: You can only submit one resubmission request at a time. If you have an on-going request, you cannot access the resubmission workflow until the pending one is resolved.
4. Applies to — Select the payer whose denial you are appealing: Primary Insurance or Secondary Insurance.
5. Resubmission type — Select a resubmission type from the menu.
6. Under Optional information, enter the following information if applicable for your resubmission request:
   1. Documents — Select medical documents or upload a new attachment to expand the section. Select the type of documentation to add. This documentation should support your appeal.
      Notes:
      • Documents that are already attached to the claim appear in the Existing Attachments section. These documents are available for athenahealth teams to use when constructing a resubmission, and do not need to be reattached via this workflow.
      • You can upload only one document via the resubmission workflow. To upload multiple documents, please complete that workflow on the claim itself before coming to this page. Uploading the documents prior to completing the new resubmission workflow allows those documents to be part of the documentation that athenahealth teams select from.
      • The Attachment type field sets the type of document you are attaching; it does not filter the medical documentation check boxes located in the Documents section.
   2. Mail-to address — Click Choose a mail-to address to expand the section. If you don’t see the appropriate address, click add a new mail-to address and enter a new address.
      Best practice: To look for additional addresses, search for the address in the Find address field.
   3. Reason for resubmission — Enter the reason for resubmitting the claim.
      Note: This field has a 2000-character limit.
   4. Claim note — Click Include claim note (internal) to expand the section. Enter any internal notes for your athenaOne practice users. Describe the reasons why the claim should be appealed, list facts to support the appeal, and indicate whether you attached any supporting documentation or faxed any documentation to athenahealth (you may want to do so).
7. Click Submit request. This action applies the PLSPPEAL kick code and moves the claim to athenahealth to review for payer-specific requirements.
   A message appears indicating that the resubmission was successfully submitted to athenahealth.
   Important: We've built automation for highly predictable resubmission scenarios: When the claim is kicked with PLSAPPEAL, athenaOne automatically executes a resubmission based on the appropriate scenario. (We’re actively building tools that limit the effects of this automation by resubmission type. If you disagree with athenaOne’s automation for the resubmission, submit a case via the Success Community: Main Menu > Support > Create Case or Call > Billing & Claims > Correct/Resubmit Claim > Create Online Case.)
   Internal note: If a case team identifies a vetted update opportunity where CRR resubmission automation is confirmed by case team members to be submitting against payer guidelines, the case team member should follow their typical process for triage/issue escalation.
   Best Practice: Case teams must confirm the payer guidelines, and complete any necessary research, prior to moving forward with the escalation.
8. An address validation window may appear if the address you entered could not be verified. Choose the address you want to use by selecting either Correct Address or You Entered, and then Confirm address.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information.
3. Actions — If the claim requires a balance adjustment, select Adjust Balance.
4. Applies to — Select the payer to which the adjustment applies.
5. Charges — Select the charges that need to be adjusted.
6. Reason — Select the reason for the adjustment.
   Note: Each adjustment reason maps to a kick reason, so that reports are unaffected.
7. Custom transaction code (Optional) — Enter a custom transaction code or enter a period to access the lookup tool.
8. Claim note — Enter a claim note explaining why the charges are to be adjusted off the claim.
9. Click Submit. This action closes the claim.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information.
3. Actions — Select Transfer Balance.
4. Select the charges that you want to adjust.
5. Transfer to — Select Patient or Next Payer.
   Note: Both options map to kick reasons, so reporting is unaffected.
6. Claim note — Enter a claim note to indicate why the balance is being transferred.
7. Click Submit. Claims with a balance transferred to Patient are kicked with PTRESP; claims with a balance transferred to Next Payer are kicked with NEXTPAYOR.

Note: At least one change must be made to the claim before it can be resubmitted. It is not compliant to resubmit a claim without changes only to see whether the claim will be paid if you resubmit it to the payer.

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Review the claim notes.
   1. If athenahealth has researched the denial with the payer, a detailed description is included.
   2. If there is an EOB or letter from the payer, click the link to review it.
3. If further clarification is needed, contact the payer directly.
4. Applies to — Select the correct insurance type.
5. Status — Select DROP.
6. Kick reason — Enter DRPBILLING.
7. Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
8. Click Save.

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Review the claim notes.
   1. If athenahealth has researched the denial with the payer, a detailed description of the documentation requested by the payer is included.
   2. If there is an EOB or letter from the payer, click the link to review.

3. If further clarification is needed, contact the payer directly.
4. Click Edit on the Attachment placeholder.
5. Type — Select the type of documentation being added to the claim.
6. Source — Select athenaClinicals document to attach a document from the patient's chart, or select Upload file to attach a file from your local computer.
7. Documents — Select the appropriate attachment from the list provided.
8. Attachment Note — Enter a note describing the attached document.
9. Click Save.
10. Scroll down to Add Note section.

In the Add Note section

11. Applies to — Select the correct insurance type.
12. Status — Select DROP.
13. Kick reason — Enter PLSAPPEAL.
14. Claim Note — Enter a note to indicate what has been attached and why an appeal of the payer's decision is requested.

If a placeholder for documentation exists in the claim, the placeholder prevents the claim from being dropped after being kicked with PLSAPPEAL, and the claim remains in HOLD status. If you believe that the requested documentation has already been sent to the payer or is not required, you can remove the attachment placeholder.

1. On the Claim Edit page, click Edit on the Attachment placeholder.
2. Attachment required — Select No, and then select a reason why the attachment is not needed.
3. Click Save. The placeholder row is updated. The attachment note changes from [Attachment Required] to [Attachment Not Required].

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Action Taken — Select From EOB.
3. Kick Reason — Enter CONTRACT.
4. Claim Note — Enter a note explaining why the charges are to be adjusted off the claim.
5. Click Save. The charges indicated will close with adjustment reason CONTRACTUAL.

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Review the claim notes.
3. Action Taken/Note Source — Select Generic Note/From Other Source.
4. Kick Reason — Select PTRESP.
5. Claim Note — Enter a note to indicate why the balance is being transferred to the patient.
6. Click Save. A statement will be sent to the patient.