Claim Review

The date this service began.

The date this service was completed.

The place of service (automatically determined from the facility).

The procedure code.

Which of the four diagnosis codes is the primary diagnosis for this service.

Which of the four diagnosis codes is the secondary diagnosis for this service.

Which of the four diagnosis codes is the tertiary diagnosis for this service.

Which of the four diagnosis codes is the quaternary diagnosis for this service.

Per-unit charge for this charge line item.

Number of units.

Used for recording National Drug Code numbers. Prints in the shaded area over the charge line for the particular line note. "N4" qualifier is appended automatically to the NDC number.

Family Planning code; used for some Medicaid programs.

Indicates that this line item is for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).

EMG indicator. CMS-1500 24I.

COB indicator. CMS-1500 24J.

To enter a line note that prints in the CMS-1500 shaded area over the charge line for the particular line note, click edit (upper right corner of the charge line) and then click Add next to Line note. This note should contain information that would pertain to a single charge on the claim (e.g., notes for an unlisted procedure code).

The type of transaction displayed (charge, payment, adjustment, transfer out, transfer in).

Note: If the EOB (claim) link appears in this field, clicking it will allow you to view and print the associated Athena Replicated EOB (AREP) and Medicare Replicated EOB (MREP).

The type of adjustment, the transfer reason, or the current kick reason.

• ACH — EFT Payment. (Automated Clearinghouse (ACH) is a transaction format that is standard across the banking industry.)
• AMEX — American Express Payment Amount.
• BADDEBT — Amount Written Off as Bad Debt.
• CAPITATED — Adjustment to close claim that is paid separately under Capitation Agreement.
• CASH — Cash Payment Amount.
• CHECK — Check Payment Amount.
  Note: If the Type column displays PAYMENT and the amount is a positive value, the charge in this row represents a takeback, that is, a posted reversal of a previous payment. A takeback can be included in check calculations, or it can be offset by a readjudication remittance record in the same batch.
• COINSURANCE — Coinsurance Transfer Amount.
• COLLECT — Amount Adjusted off into Collections.
• CONTRACTUAL — Contractual Adjustment.
• COPAY — Copay Transfer Amount.
• DEDUCTIBLE — Deductible Transfer Amount.
• DISCOVER — Discover Payment Amount.
• FEE — Collections Fee Amount.
• FREE CARE — Free Care Adjustment.
• GLOBAL — Global Adjustment.
• INTEREST — Interest Payment Amount and negative Interest adjustment to balance the claim.
• MC/VISA — MasterCard/Visa Payment Amount.
• NON — Payment offset with negative adjustment (takeback or withhold amount). Common uses for NON payment posting include when a claim is paid with a management fee or from a recoupment of funds from another claim.
• OTHER — Adjustment or Transfer that is not included in any other type shown.
• RECOVERY — Collection Agency Recovery Amount.
• UNAPPLIED — Unapplied Credit Amount.
• VENDOR-ADJUSTMENTS — This adjustment type is used when a Third Party Patient Pay vendor posts a payment adjustment. Note: When Practice Setting: Patient pay vendor adjustments is enabled, vendors can apply adjustments via an API call on the given practice.
• WITHHOLD — Amount Withheld.

The date the transaction was created and the username of the person who created the claim.

The date this transaction was last modified or voided.

Primary insurance amount of responsibility or transaction amount.

Secondary insurance amount of responsibility or transaction amount.

Patient amount of responsibility or transaction amount.

The date the action occurred.

The username of the person who took the action. AUTO indicates an automated system function.

Usernames that belong to your practice appear in regular font, but athenahealth usernames are italicized. Perot users have the prefix 'vhs' in front of their usernames.

The action taken on the claim. Highlighting indicates a system-generated action.

• SCRUB — Claim rule fired for this claim
• APPEAL — Appeal
• EOB — From EOB
• INQUIRY — Electronic Claim Status Inquiry
• MAILRETURN — Mail Return
• NOTE — Generic Note/From Other Source
• PHONE — Phone Call
• PRINT — Print Claim/View Printable Claim
• CLEARINGHOUSE — Claims Clearing-House File Check
• ERA — Electronic Remittance Advice
• TRACERESP — Claim Trace Response
• ACK PAYOR — Acknowledgement response from the payer, either direct or through a clearinghouse
• ACK PAYOR BATCH — Acknowledgement response from the payer, either direct or through a clearinghouse
• ACK INTERMEDIARY — Acknowledgement response from the clearinghouse
• ACK INT BATCH — Batch-level acknowledgement from the clearinghouse (usually a standard batch-level report)
• CLWIZARD — Claim Wizard
• CSI — Claim Status Inquiry (CSI) transaction; these Claim Notes are the default CSI history.
• CSIINFORM — Claim Status Inquiry (CSI) transaction; these Claim Notes plus the items marked CSI in the Action column are the full CSI history.

The status of the claim following this action.

A brief note describing the action, generally including a kick reason. Notes that appear here also appear under the Claim Notes section of the Claim Review, Claim Action, View Claims for Charge Entry Batch, and View Claim History pages.

For older claim notes, click [expand text] to see the text as it appeared when the rule fired on the claim.

Claim rules

• Are always associated with the Action SCRUB and the User AUTO listed in the claim notes section.
• Have a unique number identifier listed in brackets in the description.
• Are designed and built by athenahealth based on payer rules, client input, format rules for claim submission, and previous denials.

The following types of claim notes are the result of claim rules.

Note: To override a review claim note, you must have the Claim Note Override: Review role or permission. To override an advice claim note, you must have the Claim Note Override: Advice role or permission.

• Rule — Claim rules that appear with bold red Rule at the beginning of the claim note text require that the claim error be corrected before the claim is assigned DROP status and submitted to the payer.
• Review — The Review type of claim rule is designed for use by billing managers and provides an override link. The billing manager reads the review claim note, decides whether any action is needed, and then updates the claim (or not) as appropriate. Review rules are based on local claim rules created for your practice, which allow us to hold certain claims for review by your billing manager. These rules typically hold claims for issues such as medical coding or other workflow-related reasons. The Claim Note Override: Review permission controls access to the override function.
  Custom claim rules that you create for your practice are also designated as Review notes and include an override link. If overlapping custom rules of the same type are holding the claim (for example, multiple custom rules created on the Custom Rule: Invalid Modifiers page), you can override all the rules of that type by clicking the override all custom rules from same category link in the claim note.
• Advice — The Advice type of claim rule (or "claim advice") also provides an override link that allows you to override the advice without editing the claim. The text describes potential problems with the claim and still allows for outcomes contingent upon knowledge that we do not have when the rules engine scrubs the claim. The advice allows athenahealth to apply our billing knowledge on a much broader scale.
  
  What happens when you act on the advice and edit the claim? If you act on the advice claim note and the rule is cleared as the result of correction to the claim, the advice claim note appears gray. The claim is then assigned to the next appropriate status. (If there are no additional claim rule violations, the next appropriate status is DROP.)  
  
  What happens when you use the override? If you read the text of the advice claim note and determine that the advice action is not needed, you can click the override link. athenaOne then bypasses the advice, re-scrubs the claim, and assigns the next appropriate status. (If there are no additional claim rule violations, the next appropriate status is DROP.) The override event is logged in the claim note history (overridden by username, date). The Claim Note Override: Advice permission controls access to the override function. The "advice" type of claim rule is not available for practices that use athenaCollector (No Posting) and athenaCollector (No Follow-Up).

Note: An override link may also appear when a "predictive rule" fires. A predictive rule is a type of claim advice that uses historical data in athenaOne to predict likely denials, so that you can adjust them off to zero before they appear in your denial work queues. Predictive rules cover Medical Necessity Denials and Benefits Coverage (charges expected to be denied for a benefit limitation or exclusion).

Kick codes:

• Appear in green bold in brackets. Example: [CPT].
• May be preceded by the associated denial code found on the EOB. Example: [0145:CPT].
• Are assigned during payment posting and follow-up.
• Are tied to a claim status (for example, Benefits Terminated goes into HOLD).

Each payer has its own denial codes. athenaOne associates different payer denial codes to the athenahealth standard set of kick codes, which determines the appropriate next steps.

Note: When you add a claim note that sets a claim alarm, athenaOne displays the date of the alarm beneath the text of the claim note. The date appears as long as the claim alarm remains active. Claim alarms are reset every time a claim note puts a claim in — or LEAVES a claim in — BILLED status. When claim acknowledgment applies an EMCRCVD or PAYORRCVD claim note, the original alarm is cleared and a new one is set.

Claim Status Inquiry transactions:

• Claim Status Inquiry (CSI) is an ANSI-standard electronic transaction very similar to calling payers to track claims. When a claim goes to BILLED status, athenaOne automatically sends an initial claim status inquiry, then follow-up inquiries at set intervals.
• The CSI transaction results are parsed and translated into an English-language format for inclusion in the Claim Notes. The transaction response tells the user the claim level status, the amount paid on the claim, the payment date and method, and the check number (if applicable).

Note: CSI transactions are supported for athenaCollector clients only. For more information about CSI, please refer to Claim Status Inquiry.

The post date for the claim

The name and patient ID number of the patient on the claim (last name, first name, ID#).

The name of the primary insurance plan, the plan address and phone number, the subscriber number, and the first name of the insured.

The name of the secondary insurance plan, the plan address and phone number, the subscriber number, and the first name of the insured

(appears only if applicable).

The name of the supervising provider / name of the provider who actually rendered the service to the patient.

The name of the facility (department of service) where the service was provided.

(These are numbered up to 4; other) 1: The primary diagnosis code and short description; 2: The secondary diagnosis code and short description (blank if there is no secondary diagnosis; 3: 4: other:)

The post date of the charges.

The "from" service date of the charges.

The "to" service dates of the charges.

The procedure code.

Number of units.

The procedure code description.

The place of service type code for the service department. Corresponds to CMS-1500 24B.

The type of service of the charge. This may vary depending on the insurance; athenaOne determines from the procedure code on an insurance-specific basis.

The charge amount for this service.

The post date of the charges.

Time-of-service batch used to collect the patient payment.

The payment method used to make the patient payment.

The check or credit card number used make the patient payment (if applicable).

The date of service.

The procedure code and description.

The amount owed by the patient for this service.

For self-pay patients, you can use the Check Fee Schedule page (On the Main Menu, click Claims. Under RESOURCES, click Check Fee Schedule) as a quick reference tool to look up fees for procedure codes.

The amount that the patient paid for this item today.

The type of service rendered for this claim.

The expected copy for the type of service (above).

The amount the patient paid for this item today.

The coinsurance percentage required by the patient's insurance policy. Coinsurance is an alternative to copay. Use either copay $ or Coinsurance, but not both.

Coinsurance is calculated using the allowable amount from the allowable schedule for the payer and procedure code. If there is no allowable schedule for the payer and procedure code, athenaOne uses the procedure code amount as specified in the fee schedule.

For example, for a $100 charge with a 20% coinsurance, where the payer allowable schedule specifies $80 as the allowable amount, the expected coinsurance is calculated as 20% of $80, or $16. If there were no allowable schedule, the coinsurance amount is calculated as 20% of $100, or $20.

The reason for an additional payment (if the patient makes an additional payment).

The amount of any additional payment (if the patient makes and additional payment).

The total amount of patient payments made today. athenaOne auto-populates this field.