Quick Reference — To correct NCPREVIEW claims

athenaCollector

Worklist: MGRHOLD

 

Issue: The service billed is not covered by the patient's policy.

 

Next Steps: Review the EOB (if available) on the claim. Review the patient's insurance card (if available) to verify the insurance information and to verify that the correct insurance package is selected on the claim. You can ask athenahealth to appeal the claim on your behalf, or you can choose to bill the patient or adjust off the outstanding charges on 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 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 — 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.

 

  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. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page
  2. Click Add Attachments.
  3. Select Add New Attachment.
  4. Type — Select the type of attachment you want to add. This documentation should support your appeal
  5. Source — Select one of the following:
    1. athenaClinicals document – Select an athenaClinicals document to attach.
    2. Upload file — Upload a document from your computer.
  6. Attachment note — Add an internal note about the attached document
  7. Click Add Attachment.
  8. Note to Payer – Select one of the following:
    1. Default – Select this option to use the athenahealth default appeal message to the payer.
    2. Custom — Select to create a custom appeal message for the payer.
      Edit the default appeal note. This note will appear on the appeal form sent to the payer, so address it to the payer (not to athenahealth).
      Important: If you choose to draft your own appeal note, you assume the risk of the claim being denied for that appeal note. athenahealth cannot see this note.
  9. Once the file upload is complete, please click Back to Claim Edit.
  10. Applies To — Select the appropriate insurance.
  11. Action Taken — Select Generic note/From other source.
  12. Kick Reason — Enter PLSAPPEAL.
  13. Claim Note (Internal) — Enter a note for athenahealth, describing what has been attached and why an appeal of the payer's decision is requested. This not is not visible to the payer.
  14. 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.
  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.

 

  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.

 

 

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