Claim Inbox

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. In the Claim Inbox, click the My Claims tab.
3. Click Find unassigned claims.
   The Unassigned Claims window opens.
   Note: Only the worklists assigned to you appear in the list.
4. Worklist — Select the worklist from which you want to assign claims. You can assign claims from only one worklist at a time.
   Note: The Worklist Status column displays "Escalated" for escalated claims that are unassigned.
   The outstanding amount shown is a net amount (positive amounts less negative amounts). This number may increase if you work claims with negative outstanding amounts (for example, refunds).
5. (Optional) Select a value in the second filter on the left to reduce the number of claims that appear on the right.
   Note: You can configure the second and third filters on the Claim Worklists page.
6. (Optional) Select a value in the third filter on the left.
7. Select claims to assign to yourself.
   Note: You can assign up to 100 claims to an individual at a time. Your practice can configure the maximum number of claims that can be assigned using the Claim Worklists page.
8. Click Assign. The selected claims appear in your My Claims tab.
   Note: By default, assigned claims are released into an unassigned status after 1 business day. Configure this value using the Claim Inbox Settings page.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. In the Claim Inbox, click the My Claims tab.
3. Click the Claim ID link for a claim in the table.
   The claim list appears in the Task Bar, and the Claim Action page appears.
   Note: If your practice is part of a reporting network that includes multiple practice IDs and you click a claim that exists in a practice other than the practice you are logged in to, the Claim Action page for the claim you selected appears in a separate pop-up window and no worklist appears in the Task Bar.
4. Work the claim.
5. You can click the links in the Task Bar to access and work additional claims.
6. Click Open My Claims (n) to resort/filter to return to the Claim Inbox.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
3. Click Assign next 10 claims.
4. Select the worklist from which you want to assign claims.
   Note: Only the worklists assigned to you appear.

The default sort groups claims by Payer and by Hold Reason, and sorts those groups by the average outstanding amount. This sort is worklist-specific and the link is clickable only if you filter your claims table to a single worklist.

Note: The criteria used to sort and group claims is configured on the Claim Worklists page.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
3. In the Filters section, select a single Worklist to filter.
4. Click Apply default sort.
   The claims table refreshes to group similar claims together.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
3. Click Update filter criteria.
4. Select filters.
5. If you want to save these filters, select the Save as default option. The selected filters will be applied when you open this tab in the future.
6. Click Filter.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab to display your worklist.
3. Click Configure Columns.
4. Select the columns that you want to appear in the table.
5. Click Save.
   Note: The selections you make remain in force until you edit the columns displayed by clicking Configure Columns.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
3. Select one or more claims to pend.
4. In the gray bar pinned to the bottom of the page, click the Act on menu and select Pend.
5. Days to pend — Enter the number of days for which you want to pend the claim (up to 99).
6. Return to me after pend — Select this option to return the claim to your My Claims tab after the pend expires, instead of returning it to Unassigned status.
7. Add a claim note describing the reason for pending the selected claims.
8. Click Submit. The pended claims appear on the Pended Claims tab.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the Pended Claims tab.
   Note: Users with the Claim Worklists: Work Claims permission can see only claims that have been pended by them. Users with the Claim Worklists: Manager Access permission can see all claims pended in their worklists, although the default filter option shows claims pended by them.
3. Apply filters, configure columns, or sort the table to find a group of claims to work together.
4. Click the Claim ID link for a claim in the table.
   The claim list appears in the Task Bar, and the Claim Action page appears in the Workspace.
5. To unpend these claims (and move them to their next status, either assigned or unassigned), select one or more claims.
6. Act on — Select Unpend.
7. Click Submit.
   Note: Claims that are unpended and reassigned to the pending user have an exclamation point icon () indicating that status.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
3. Select one or more claims to escalate.
4. Act on — Select Escalate.
5. Select escalation contact — Select the user to whom you are escalating the claims.
   Note: You can escalate claims to any user with the Claim Worklists: Manager Access user permission.
6. Select escalation reason — Select the escalation reason.
7. Add a claim note describing the reason for escalating the selected claims.
8. Click Submit.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the Escalations tab.
   Note: Users with the Claim Worklists: Work Claims permission can see only claims that have been escalated by them. Users with the Claim Worklists: Manager Access permission can see all claims escalated in their worklists, although the default filter option shows claims escalated by them.
3. Apply filters, configure columns, or sort the table to find a group of claims to work together.
4. Click the Claim ID link for a claim in the table.
   The claim list appears in the Task Bar, and the Claim Action page appears in the Workspace.
5. Select one or more claims.
6. Act on — Select one of the following:
   • Reassign — Select the user to whom you want to assign the claims. This option is available only to users with the Claim Worklists: Manager Access permission.
   • De-escalate — De-escalated claims return to Unassigned status.
7. Click Submit.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
3. Select one or more claims to which you want to add the same claim note.
4. Act on — Select Add claim note.
5. Add a claim note.
6. Click Submit.
   Note: The claim note appears in the claim history for each selected claim.

Note: Only users with the Claim Worklists: Manager Access permission can apply kick codes.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
   Note: You can also apply kick codes to claims on the All Claims and Escalations tabs.
3. Select one or more claims to which you want to apply the same kick code.
4. Act on — Select Apply kick code.
5. Select the kick code from the menu.
   For the list of kick codes available from the menu, see Kick codes available on the Claim Inbox page.
6. Add a claim note.
7. Click Submit.
   Note: The kick code and claim note are applied to all the selected claims.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the My Claims tab.
3. Select one or more claims to release.
4. Act on — Select Release.
5. Click Submit.
   Note: Releasing claims returns them to an unassigned status, allowing other users to find, assign, and work these claims through the Claim Inbox.

Note: Only users with the Claim Worklists: Manager Access permission can view or assign all claims in hold.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the All Claims tab.
   Note: If you click the Download to Excel link before you select a worklist, all worklist records in all your practice worklists are downloaded.
3. Select a worklist from the menu. The All (n) option in the menu displays all claims for all worklists.
   Note: Users with the Claim Worklists: Access All Worklists permission can select show my teams or all. My teams is selected by default and shows only worklists to which you are assigned. The all option shows all practice worklists.
4. Apply filters, configure columns, or sort the table to find groups of similar claims.
5. Use the Act on field to assign or reassign the selected claims to a specific user.
   Note: When claims are assigned to a user from the All Claims tab, they appear with an exclamation point icon () in the user's My Claims tab.

Note: Only users with the Claim Worklists: Productivity Reporting permission can run a productivity report.

1. Display the Claim Inbox: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Under My Worklists, click Claim Inbox. The Claim Inbox appears in the Workspace.
2. Click the Performance tab.
3. View by — Select Worklist or User.
4. Date — Select a date range.
5. Team — If you selected Worklist from the View by menu, select the teams to include in the report.
6. Users — If you selected User from the View by menu, select the users to include in the report.
7. Click Filter.
8. Click Download to Excel to download all the claim data for the reporting period.

Practices who are part of a reporting network can request access to the same custom claim worklists functionality that non-networked practices have as follows:

1. Before contacting athenahealth, complete your worklists, or get a list of your queued claims.

2. Contact your CSM or onboarding project team and request that the Additional Custom Claim Worklists Functionality for Practices in Reporting Network feature be enabled.
   Important: When this feature is enabled, your queues are reset, so any queued claims will be removed from the queues and reset to their original state.

What additional functionality can be accessed?

 

If your practice is part of a reporting network, you can access the following functionality only if the Additional Custom Claim Worklists Functionality for Practices in Reporting Network feature is enabled for your organization. This allows you to access the same functionality that's available to non-networked practices.

Additional options within the filter

The following additional fields appear on the My Claims, Pended Claims, and Escalations tabs of the Claim Inbox page when you click Update Filter Criteria:

• Diagnosis codes

• Patient department

• Primary department

• Specialty

Additional options within Configure Table Columns

The following additional fields appear on the My Claims tab of the Claim Inbox page when you click Configure Columns:

• Diagnosis codes

• Patient Department

• Primary Department

• Referring Provider

• Specialty

Ability to work all tasks within the Claim Edit page

You have additional options to work tasks within the Claim Edit page:

• The Claim Inbox menu appears in the top right, next to the Resources menu, and contains the following options:

  • Assign Claim

  • Go to Claim Inbox

• Additional option in the Resources menu:

  • View Clinical Encounter

• Additional options in the claim Actions menu on the Claim Action page:

  • Adjust Balance

  • Appeal Denial

The Claim Inbox provides the following tabs:

Claim Worklists tab

 

This tab requires the user permission Claim Worklists: Access All Worklists or Claim Worklists: Manager Access.

 

The Claim Worklists tab provides a high-level summary of each worklist, including the team, outstanding amount, total number of claims, number of unassigned claims, and average age (days since date of service).

 

My Claims tab

 

This tab requires the Claim Worklists: Work Claims user permission.

 

The My Claims tab provides a view of all the claims currently assigned to the user.

 

Pended Claims tab

 

This tab requires the Claim Worklists: Work Claims user permission.

 

The Pended Claims tab provides a view of all claims that the user has pended.

 

Escalations tab

 

This tab requires the Claim Worklists: Access All Worklists or Claim Worklists: Manager Access user permission.

 

The Escalations tab provides a view of all claims that have been escalated to the user.

 

Performance tab

 

This tab requires the Claim Worklists: Productivity Reporting user permission.

 

The Performance tab provides a productivity report by worklist or by user, including the number of claims assigned, worked, escalated, pended, released, and not worked.

 

The Performance tab measures user activity on worklist records. A worklist record is a single hold event on a claim. Typically, a claim can have only one active worklist record at a time, but it may generate multiple worklist records before the claim is resolved entirely. Clearing a worklist record does not necessarily mean that the claim was successfully resolved, only that the single hold event was cleared.

 

A worklist record may have multiple actions taken on it before it is cleared. As a result, the record may be counted multiple times in each metric. For example, if a user pends a claim twice, that record is tallied twice in the pended metric.

 

The Inflow and Outflow metrics show the number of worklist records that move in and out of that worklist for any reason. Other than being resolved, a worklist record can enter or leave a worklist due to a reconfiguration of your worklists. If you have only a Default Worklist, this scenario does not apply.

 

In the Claim Inbox, the current error is the active hold reason that qualifies the claim for that worklist. In the default worklist, the current error is always the most recent kick code applied.

You can use the Claim Worklists page to configure custom worklists with a kick code or rule filter. A custom worklist searches all the active hold reasons on the claim and sets the current error as the hold reason defined in the worklist configuration. In a custom worklist, the current error may not be the most recent kick code or rule.

For example, if a claim has two active (unresolved) hold reasons — CREDENTIAL, which fired on 11/1/2020, and AUTH, which fired on 11/10/2020 — and you have only the default worklist, the current error will be AUTH. If you create a new worklist that pulls in all claims with a credentialing hold, the current error will be CREDENTIAL.

Claims can be escalated for several reasons:

• The user does not know how to work the claim.
• The claim should be in a different worklist.
• The claim needs to be addressed by a user with different expertise, for example, a practice manager or billing manager.

To view escalations, a user must have the Claim Worklists: Access All Worklists or Claim Worklists: Manager Access user permission.

You can use the Claim Inbox page or the Claim Worklist Dashboard page to escalate claims out of a worklist. If you cannot work a claim because it is improperly categorized or you do not have the expertise to correct the claim, you can move that claim to another user using the tool, eliminating the need to phone or send email.

The claim escalation does not route claims to athenahealth. The escalated claim disappears from your My Claims list and appears under a new heading, indicating an escalation.

The escalation point of contact can work the claim, reassign the claim to another user, or de-escalate the claim back to its original worklist.

Escalated claims never leave their assigned worklist, and they remain in a general pool of claims available to many users. The key difference between an escalated claim and a regular claim is the order in which claims are assigned to users with different permissions. Users who are expected to address escalations are assigned escalations before any other claims (if present). All other users are never assigned escalations.

The following filter fields appear on the My Claims, Pended Claims, and Escalations tabs of the Claim Inbox page.

On the My Claims tab, you can click Configure Columns to display a list of columns to show or hide in your claim lists. The following table shows all available columns for the My Claims tab.

Alert ()	Indicates that this claim has been assigned an alert.
Claim ID	Claim ID.
Payer	The insurance reporting category of the insurance package in the current claim status. For example, if the claim is in Primary HOLD, this field displays the IRC of the primary insurance package.
Custom Insurance Group	Custom insurance group of the insurance package.
Insurance Package	Name of the insurance package in the current claim status.
Outstanding Amount	Current outstanding dollar amount associated with the current claim status.
Date Of Service	Date of service for the claim.
Diagnosis Codes	Diagnosis codes associated with the claim.
Procedure Code	Procedure code associated with the claim.
Hold Reason	Current error on the claim.
Hold Date	Date of the current error (hold reason).
Days In Status	Number of days that the claim has been in the current status.
Primary Department	Primary department listed on the patient's Quickview.
Patient Department	Patient department listed on the claim.
Service Department	Facility listed on the claim.
Supervising Provider	Name of the supervising provider listed on the claim.
Rendering Provider	Name of the rendering provider listed on the claim.
Referring Provider	Name of the referring provider.
Provider Group	Provider group for this claim.
Patient Name	Name of the patient listed on the claim.
Worklist	Worklist where this claim is assigned.
Last Claim Note	Date of the last claim note added to the claim. Click the date to display the claim note.
Claim Status	Current status of the claim, for example, HOLD, MGRHOLD, or OVERPAID.
Specialty	Specialty of the supervising provider listed on the claim.

Following is the list of kick codes that you can assign to one or more claims on the Claim Inbox page, with the next claim status and the balance transaction type (N/A means "not applicable").