Quick Reference — To request that athenahealth appeal a claim

athenaCollector

 

To edit claim information, you need both of these user permissions:

• Claim Edit Pages — This user permission provides view access to pages used to edit claims.
• Edit Claims — This user permission provides view access to pages used to edit claims and allows the user to add, edit, and delete information on a claim.

When you appeal a claim, attach or fax supporting documentation (medical records, labs, etc.) and follow these steps.

Note: For instructions on attaching documents to claims, see the Manage Attachments page.

To request an appeal from the Claim Action page

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.

To request an appeal from the Claim Edit page

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.