Quick Reference — To create a Cost Estimate for a self-pay patient appointment

1. View an existing patient appointment that hasn't been checked in yet.

2. The following fields on the Appointment page can impact the cost estimate:
   

   Field name	Description
   Department	The Department for this appointment   Note: If the Department is changed, any existing Cost Estimate will display warning icons and messages so you know the estimate is outdated. You can click Refresh cost estimate to update the estimate based on the updated Department.
   Primary Insurance	Select Self-Pay or No-Insurance/Self Pay. If your practice has the Post-Adjudication Sliding Fee Plans practice setting = OFF: To apply a sliding fee discount in the cost estimate, select a sliding fee plan as the patient's Primary Insurance on the Appointment page.
   Sliding Fee Plan	Note: This field will only appear if: Your practice has the Post-Adjudication Sliding Fee Plans practice setting = ON AND The patient has sliding fee plans defined in their insurance in Quickview: To apply a sliding fee discount in the cost estimate, select a sliding fee plan here.   Tip: Click the image to see an expanded view
   Upcoming appointment	The date/time of the upcoming appointment

   
   
   

3. In the Cost Estimate section, you can create a self-pay cost estimate:

   
   

   Note: The Cost Estimate section will only appear if the patient's Primary Insurance is Self-Pay or No-Insurance/Self Pay.

    

   

   Tip: Click the image to see an expanded view

    

   Field name	Description
   Primary Insurance	(view-only)
   Department	(view-only)
   Sliding fee plan	(view-only)
   Upcoming appointment	(view-only)
   Select a template below or enter procedure codes and modifiers	Select a Cost Estimation Template based on the department.   (if your organization has not created any Cost Estimation Templates in athenaOne, the template menu will be blank and you will need to manually enter procedure codes and applicable modifiers.)
   Procedure Code, Modifiers     Units	If you selected a Cost Estimation Template: athenaOne automatically populates the Procedure code,Modifiers and Units fields with the procedures your organization defined in the selected template. Edit the defaulted values if needed. Note: Adding or removing procedure codes or units during estimate creation does not change the template.   If you did not select a Cost Estimation Template: Enter Procedure Codes, Modifiers and Units for the patient's appointment. This field uses the same Procedure Code Lookup which is available on many athenaOne pages such as Charge Entry and Claim Edit. Enter "." or "?" to search for a procedure code by description or code.   The following appears for each Procedure you enter: Description — The description of the procedure Cost — The cost of the procedure based on the Units entered and the fee schedule Note: You need at least one procedure code/procedure code-modifier combination to create a self-pay cost estimate.

   
   

4. Click Create Estimate.
   

   The estimate appears, with the sliding fee discount applied if applicable, and a message letting you know the status of the estimate creation.

   
   

   

   Tip: Click the image to see an expanded view
   

    

   Note:

   • The cost estimate will not reflect any local rule sliding fee adjustments.

   • If your organization has Practice Setting: Post-Adjudication Sliding Fee Plans = OFF) — The cost estimate uses the sliding fee plan selected in the Primary Insurance in the Appointment.

   • If your organization has Practice Setting: Post-Adjudication Sliding Fee Plans = ON) — The cost estimate uses the Sliding fee plan selected in the Appointment.

   
   

5. Click Print Cost Estimate to send the estimate to a printer.
6. If you share the cost estimate with the patient, click the box next to Cost estimate has been shared with the patient.

In the View Appointment page, once you have a cost estimate created for a self-pay patient, you can also create and share a Good Faith Estimate form (CMS-10791 form). The form can be printed or emailed to patients to support compliance with the No Surprise Billing legislation (i.e. No Surprises Act).

1. In the Cost Estimate section, click Create and share Good Faith Estimate (No Surprises Act: CMS-10791) .

   
   

   

    

   A pop-up window appears.

   
   

2. Create and share Good Faith Estimate (No Surprises Act: CMS-10791)

    

   

   Tip: Click the image to see an expanded view

    

    

   Field name	Description
   Procedure, Modifiers	(view only)
   Units	(view only)
   Description	(view only)
   Optional: Diagnosis code	Enter a diagnosis code for each of the CPT codes in the cost estimate. You can enter up to four Diagnosis codes for each CPT code.   Note: The system does not validate the diagnosis code. (Even if you enter an invalid diagnosis code, you can still generate the form.)
   Diagnosis description	(view only)
   Cost	(view only)
   Additional health care provider/facility notes	Enter any additional notes to appear on the Good Faith Estimate form. If you have sliding fee discounts, you can enter details here. This field is limited to 500 characters.

   
   

3. Click Create Form to generate a digitized copy of the CMS-10791 Good Faith Estimate for Health Care Items and Services form, with the following fields populated:

   
   

   Fields	Populated from...
   Patient information	the patient's appointment data and registration information in athenaOne
   Procedures/ Modifiers, Estimated Cost	information entered in the Cost Estimate section of the appointment
   Diagnoses/ Additional health care provider/facility notes	information entered in the Create and Share Cost Estimate window
   Provider details Street Address City State Zip Code Contact Person Phone Address where service/item will be provided	the provider specific to the appointment Department (the physical location where the services are rendered); if Department information is not available, then use provider from the Medical Group (except for the Contact field — if information is not available from the Department, the field is left blank)

    

   
   

4. Use the options at the top to email or print the form:
   

   • Email form to — Select one of the listed contacts from the patient's registration or select Other, which allows you to type in an email address.

   • Send — Email the form to the selected address.

   • Print — Print the form.
     

      

     

    

   See the Good Faith Estimate — generated email and form (images) section below for an example of the generated email and form.

   
   

5. Close the window to return to the Cost Estimate section in the View Appointment page.

6. After you have created and shared a Good Faith Estimate, you'll see different options at the top of the Cost Estimate section:
   

    

   

   
   

    

   Link	Description
   Share existing Good Faith Estimate Last shared: MM/DD/YYYY	Click this link to share the existing version of the Good Faith estimate form(CMS-10791 Form), which was printed or emailed to the patient upon creation of the form.   The timestamp shows when it was last shared.
   Create and share new Good Faith Estimate	Click this link to create a new version of the form. The pop-up window appears — enter the Diagnosis Codes and Additional Notes. Then click Create Form to generate a new version of the Good Faith estimate form with the updated Diagnosis Codes and Additional notes.

Good Faith Estimate — email sent to patient

 

This is an example of the email that is sent to the patient if you choose to email from the Create and share Good Faith Estimate (No Surprises Act: CMS-10791) window:

 

Tip: Click on the image to see an expanded view

 

Good Faith Estimate — athenahealth's digitized version of the CMS-10791 form

 

 

This is an example of the form that is created from the Create and share Good Faith Estimate (No Surprises Act: CMS-10791) window:

 

Tip: Click on an image to see an expanded view

 

 

 

 

 

 

 

Note: 

• Once a patient is checked in, you can no longer go back to the Appointment page and therefore can no longer update the cost estimate.

• Once a claim is created for an appointment, you can no longer view or change the cost estimate.

1. View an appointment that has not been checked in yet.

2. In the Cost Estimate section, click Update Estimate .

3. Procedure Code, Modifiers — Add, edit or remove Procedure Codes and Modifiers.

4. Click Create Estimate to update the existing estimate, or click Cancel.
5. If you updated the procedure/modifier combinations and then click the Create and share new Good Faith Estimate link, you'll see the updated cost estimate in the pop-up window and the workflow continues as explained above.

If there is a change in any of the Appointment information used in the cost estimate, the cost estimate will need to be updated (refreshed).