Quick Reference — To correct NEREVIEW claims

athenaCollector

Worklist: HOLD

 

Issue: Patient may not be eligible for this date of service for the insurance package being billed. The incorrect insurance package may have been selected for the claim, or the patient may need to contact the payer to update the coordination of benefits information.

 

Next Steps: Review the EOB (if available) on the claim. Scan and upload a copy of the patient's insurance card and review it to verify insurance information (contact the patient if necessary). If you disagree with the adjudication, you can ask athenahealth to appeal the claim. You can also bill the patient based on your practice policy.

  • The patient's eligibility is in question by the payer.
  • Expenses were incurred after coverage was terminated.

 

  • Verify patient insurance, make necessary corrections and resubmit the claim
  • Request athenahealth appeal the claim
  • Transfer the balance

Note: If after acting on this error, the claim remains in a hold status (HOLD or MGRHOLD), the claim requires additional review or work.

 

First, run an updated DOS eligibility check through athenaOne. Based on that response, contact the patient to verify eligibility with the insurance carrier. If the patient has new information about the current insurance policy, display the Quickview and update the insurance information. If another insurance needs to be billed, obtain the insurance information. If this new insurance package does not exist in the patient record, display the Quickview and add the insurance package. If the insurance information is correct, ask the patient to contact the payer for details about eligibility.

 

 

  1. Display the Claim Edit page: Click the edit claim link on the Claim Review or Post Payment page (the link is on the line item's advanced view).
  2. Make sure that there is an open balance in the payer column. For example, to bill a different primary, there must be an open balance in the primary column of the claim.
  3. Void any previously posted adjustments and transfers in the payer columns that you wish to change.
    • Do not void any payments or takebacks.
    • If you billed the incorrect payer in error and that payer paid on the claim, contact the payer to issue a refund.
    • If the balance cannot be opened properly because of the way payments are posted, contact the athenahealth CSC by selecting Support > Create Case or Call in the Main Menu.
  4. Primary Payer or Secondary Payer — Select the correct payers. A message alerts you that all transactions except for payments will be switched to the new payer when you select it.
    If the desired insurance is not listed in the menu, add the insurance package to the patient's list of insurances.
  5. Click OK.

 

 

 

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 — 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. Display the Claim Edit page: In the text box at the top right of your screen, enter the claim number, select Claim ID from the menu, and then click the search icon. The Find tool looks for an exact claim ID match. (Searching for claims requires claim billing user permissions.).
  2. Review the claim information and existing documentation.
  3. In the Add note section, click Resubmit to Payer.
    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. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
  2. Review the claim notes.
    • If athenahealth has researched the denial with the payer, a detailed description is included.
    • If there is an EOB or letter from the payer, click the link to review it.
  3. Scroll down to the Add Note section.
  4. Applies to — If needed, select the payer type for the claim note: Primary Insurance or Secondary Insurance.
  5. Status — Do not change the status.
  6. Kick reason — Enter PLSAPPEAL.
  7. Note — Enter a note about the appeal.
    Important: To assist athenahealth users who are finalizing your appeal package, please clearly label and differentiate between your appeal note (payer facing) and your internal claim note, for example:

  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.
  3. Action Taken/Note Source — Select Generic Note/From Other Source.
  4. Kick Reason — PTRESP or NEXTPAYOR.
  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.

    Note: If athenahealth receives adjudication back from a payer that is not listed on the patient's Quickview or under the View Cancelled Insurances section, and that payer can be matched to a specific claim, athenahealth selects the insurance package Unspecified Remit Payor to post per the EOB.

    This happens most often when Medicare crosses over a claim to a payer not listed in the patient's account and chance the secondary payer on the Claim Edit page to that payer.

    After adding the correct insurance package to the claim, the claim posting of the secondary column will still show Unspecified Remit Payor. To correct this, please submit a support case asking for the claim to be posted to the correct secondary payer, or contact the CSC by selecting Support > Create Case or Call in the Main Menu.

 

 

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