Quick Reference — To correct TAKEBACK claims

athenaCollector

Worklist: MGRHOLD

 

Issue: A provider takeback record represents funds deducted from a payment amount. The record may include charge-level details.

 

Payers will often recoup all or a portion of a prior payment in the form of a takeback. These are typically the result of prior overpayments and readjudication of claims.

 

If athenahealth is unable to obtain information from the payer regarding the takeback, athenahealth forwards the record to your MGRHOLD worklist, so you can review it and provide any necessary posting information.

 

Next Steps: Please request an offset from the payer or refund the overpayment if the payer cannot issue an offset.

  • Make an adjustment
  • Request offset from the payer or refund the overpayment
  • Transfer the balance
  • Update the payer and resubmit the claim
  • Request that athenahealth appeal the claim

In most situations, action may not be necessary on a claim that is undergoing a takeback. When a claim is kicked with TAKEBACK, review the following:

  1. Click the EOB link for the takeback,
  2. Review the EOB.The EOB gives the reason for the takeback, the amount recouped, and where the amount was taken from.
  3. Review the balance for the next appropriate action to take on the claim
    1. If another insurance should be billed for this claim, change the payer and resubmit the claim.
    2. If this claim should be billed to the patient, use the appropriate kick code to transfer the balance. Please ensure that adjustments and transfers have been properly voided.
    3. If the takeback was incorrect, please contact the payer representative.

If the record contains charge level details, athenaOne logic ensures that the record is matched to its associated Balance Forward or Readjudication Notice.

 

If the record does not contain charge level details, the record is reviewed by athenahealth for the next appropriate steps.

 

Payers often recoup all or a portion of a prior payment in the form of a takeback. These takebacks can occur for several reasons, the most common of which are prior overpayments and readjudication of claims. Typically, provider takebacks will automatically match earlier Readjudication Notice or Balance Forward record types, and the offsetting pairs will close.

 

Often, the information provided by the payer on the EOB is insufficient to accurately post to record in athenaOne. In these cases, the amount of the takeback in question is created and tagged with identifying information. These record types include events that move the record appropriately through the workflow. Actions should be taken based on the event in the record.

 

 

Action: Close the Remittance Record as "Posted to Foreign system," and then post this record in your foreign system.

 

 

 

Payer unable/unwilling to provide details necessary to resolve provider takeback

 

When this event is accompanied by a note stating that multiple call/contact attempts have been made and the payer has been unable/unwilling to provide the details necessary to resolve the provider takeback, follow these steps.

  1. Review the record to see whether you received the information needed to resolve the provider takeback
  2. If the related information is located, please return the Remittance Record to athenahealth with the additional information documented in notes, so that athenahealth can post the remittance.

Payer did not acknowledge receipt of the refund posted

 

When this event is accompanied by a note stating that a refund has posted a refund for the claim associated with the takeback, but the payer did not acknowledge receipt of the refund and took back the funds anyway, follow these steps.

  1. Find a copy of the refund check sent and call the payer with that information to confirm receipt of the refund.
  2. After the payer acknowledges receipt of the refund, ask the payer to issue a rebate check to offset the provider takeback.
  3. Return the record to athenahealth stating that the payer will issue a rebate check.

 

 

 

Review the claim to determine whether a takeback has been posted to the appropriate claim lines or a remittance record associated with a takeback has been posted in the claim notes. Takebacks appear as a positive payment line on claims, essentially reopening your AR for that charge line.

 

  1. Review the posting for accuracy according to the EOB.
  2. If the posting is correct, no further action is needed.

 

  1. Review the relevant EOB to determine whether the EOB is for an actual takeback or a non-financial (informational) takeback, which should be a Balance Forward remittance record
  2. Look in the summary page of the EOB. If the total of the paid claim is more than the actual check that the payer sent, this EOB is usually an actual takeback EOB

 

 

  1. If the payer is a PCN Matching payer, we post the takeback to the claim and create the Balance Forward remittance record.
  2. In the claim notes, you should see a Balance Forward remittance record that is in an open status.
  3. Click the unpostable link in the claim note and review the remittance record notes. The Balance Forward remittance record is a placeholder for the future recouped item of the funds. If Medicare is the payer, athenahealth has an automated system in place.
  4. No action is necessary. The takeback EOB will come in and athenahealth will post the takeback accordingly.
  5. Contact the payer directly to complete a refund instead of allowing the takeback to be processed.
  6. If the payer agrees to a refund instead of a takeback, follow the refund steps.

 

athenahealth process for posting provider takebacks and remittance

  1. athenahealth receives the original payment and will post it against the charges on the claim.
  2. When we receive a charge reversal/readjudication, we post a takeback of the original payment, and we reverse all previously posted transfers and adjustments.
  3. We post the new adjudication and create a Readjudication Notice record to offset the claim level takeback amount. We also add a link in the claim note to the Readjudication Notice.
  4. If a refund request letter arrives, we create a Refund Request Letter remittance record. athenaOne automatically attempts to match the individual refund requests to the relevant claims via the Readjudication Notice records.
  5. When the Refund Request letter arrives, immediately initiate an offset request or refund payment to Medicare. If Medicare does not receive the offset request or refund payment in the number of days stated on this letter, they will issue a provider takeback remittance record and interest may accrue.
  6. If Medicare issues a provider takeback, we create a Provider Takeback remittance record for the takeback amount. athenaOne automatically does the following:
    1. Searches the system for the matching Refund Request Letter and any related Readjudication Notice records.
    2. Links the Provider Takeback to the related claims.
    3. Closes all related remittance records.
    4. These actions complete the series of transactions related to the readjudication. athenaOne identifies related remittance records by the record amount and the payer's Internal Control Number (ICN/PCN), a unique numerical identifier that Medicare and other commercial payers use to track transactions in their systems. The ICN/PCN connects the provider takeback to the Refund Request Letter and the Readjudication Notice.
  1. If Medicare collected interest because of the takeback, athenahealth creates a separate Interest Payment remittance record for the interest amount.

 

 

If athenaOne cannot automatically close a provider takeback remittance record and we cannot identify its matching records, athenaOne forward the remittance record to athenahealth to request identifying information from the payer. If the payer does not provide identifying information, athenahealth will forward it for review. If the record is identified, return to athenahealth for processing.

 

Your organization is responsible for requesting an offset from the payer or refunding the overpayment if the payer cannot issue an offset (provider takeback remittance record).

 

Your organization is for working any holds on the claim from posting the readjudication remittance.

 

 

 

  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. 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. 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.

 

 

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.
  1. If further clarification is needed, contact the payer directly.
  2. Click Edit on the Attachment placeholder.
  3. Type — Select the type of documentation being added to the claim.
  4. 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.
  5. Documents — Select the appropriate attachment from the list provided.
  6. Attachment Note — Enter a note describing the attached document.
  7. Click Save.
  8. Scroll down to Add Note section.

In the Add Note section

  1. Applies to — Select the correct insurance type.
  2. Status — Select DROP.
  3. Kick reason — Enter PLSAPPEAL.
  4. 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].

 

 

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