Claim Worklists

1. Display the Claim Worklists page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Claim Worklists, click Claim Worklists.
2. Click add new. Additional fields appear.
3. Worklist name — Enter a name for the worklist. We recommend using standard naming conventions across all your worklists.
4. Priority — Select the priority for the worklist.

   The first time you set a priority, it defaults to "1." athenaOne populates claim worklists in order of priority, so claims are not assigned to more than one worklist at a time. For example, if you create a worklist for all Blue Cross claims with priority 1 and you create a second worklist for coding denials with priority 2, athenaOne will assign a Blue Cross coding denial to the Blue Cross worklist because that worklist has the higher priority.
   Note: The "Default Worklist" is always the lowest priority. athenaOne assigns all claims that do not meet criteria for any other worklist to the "Default Worklist."

5. Worklist team — Select a team to assign to the worklist.
   Note: This field is populated with the teams created using the Claim Worklist Teams page.
6. Claims per request — Select the number of claims to assign for each "assign" request in the Claim Worklist Dashboard.
   Note: Depending on your practice configuration, you may not see this field.
7. Maximum claims per user — Select the maximum number of claims that athenaOne can assign from this worklist to any user at a given time.
   Note: This limit applies only to this worklist. If a user is assigned to one worklist with a limit of 10 claims and to another worklist with a limit of 20 claims, athenaOne can assign that user a total of 30 claims from these two worklists.
8. Notes — Enter additional details about the worklist.
9. Instructions — Enter any instructions associated with this worklist. These instructions will appear at the top of the Claim Edit or Claim Action page for claims in this worklist accessed through the Claim Inbox.
   Note: This field appears only for practices that have multiple departments set up.

Worklist Defaults

10. Pend claims for — Select the default pend duration for claims in the Claim Inbox. This number can be overridden in the Claim Inbox by the user.
11. Return pended claims to user — Select the default behavior for unpended claims. If you select Yes, pended claims return to the user who pended them. If not, pended claims return to an unassigned status.
12. Primary grouping — Select the primary attribute on which to group claims. This attribute will appear as the first filter in the Unassigned Claims window in the Claim Inbox.
13. Secondary grouping — Select the secondary attribute on which to group claims. This attribute will appear as the second filter in the Unassigned Claims window in the Claim Inbox.
14. Sort by — Select the value on which to sort the claim groups defined above. This value is displayed in the Unassigned Claims window in the Claim Inbox.

Claim Attributes

Note: If you created custom filters on the Custom Filters page, you can view and select the custom filters in the Claim Attributes section of this page.

15. Claim status — Select the status of claims to include in this worklist.
16. Transfer type — Select the insurance type to include in this worklist.
17. Context — Select the practices to which this worklist applies. This attribute appears only for athenaEnterprise organizations.
18. Department — Select the departments to which this worklist applies.
19. Provider group — Select the provider groups to which this worklist applies.
20. Provider — Select the supervising providers to which this worklist applies.
21. Insurance reporting category — Select the insurance reporting categories (IRCs) to which this worklist applies.
22. Referring Provider — Select the referring providers to which this worklist applies.
23. Custom insurance group — Select the custom insurance groups to which this worklist applies, if your practice has set up custom IRCs (a collection of insurance packages defined by your practice).
24. Insurance package — Select the insurance packages to which this worklist applies. If you select this attribute, you disable the Insurance reporting category and Custom insurance group attributes.
25. Procedure code — Select the procedure codes to which this worklist applies. Click Selected and specify the procedure codes in the fields provided. You can type a period in any field to display the Procedure Code Lookup tool.
    Note: You can use wildcard characters in this field, for example, you can enter 992*.
26. ICD-10 Diagnosis code — Select the diagnosis codes to which this worklist applies. Click Selected and specify the ICD-10 codes in the fields provided. You can type a period in any field to display the ICD‑10 lookup tool.

27. Outstanding amount — Select At least to enter a minimum dollar amount; select At most to enter a maximum dollar amount.
    Note: If you do not specify a minimum or maximum outstanding amount, the worklist includes all claims, including those with a zero or negative balance.

28. Days since service date — Select At least to enter a minimum number of calendar days that a claim must be in its current status since the date of service; select At most to enter a maximum number of calendar days that a claim must be in its current status since the date of service.
    You can use this attribute to help you work claims on a first in, first out (FIFO) basis (which athenahealth recommends) by creating separate worklists for backlogs of claims that may not be of the highest priority.
29. Days since claim was put in this status — Select At least to enter a minimum number of business days that a claim must be in its current status; select At most to enter a maximum number of business days that a claim must be in its current status.
    You can use this attribute to help you work claims on a first in, first out (FIFO) basis (which athenahealth recommends) by creating separate worklists for backlogs of claims that may not be of the highest priority.
30. Days since last action taken on claim — Select At least to enter a minimum number of days since the last action was taken on the claim; select At most to enter a maximum number of days since the last action was taken on the claim.
    Only claims that have been edited within the number of days specified by this filter appear on the worklist. (Any change on the Claim Edit or Claim Action page, including adding a claim note, counts as editing a claim.)

Claim Issues

31. Select All of the selected if you want the worklist to include only claims that match all of the Claim Issues filters that you specify. Select Any of the selected if you want the worklist to include claims that match any of the Claim Issues filters that you specify.
32. Issue type — Select one or more of the following claim issues:
• Audit Claims — Primarily Recovery Audit Contractor (RAC) claims identified via the athenaOne posting process.
• Denials and Other Kickcodes — Claims that are holding due to an active kick code, which may have been appended to the claim via a payer denial, applied manually, or applied automatically.
• Front end scrub — Claims that are holding for an active claim rule (global, local, network, or custom).
• Fully worked — Claims with a Fully Worked Receivable (FWR) status.
  Note: All FWR claims are in MGRHOLD, regardless of the status that the current error normally maps to.
• Not yet billed — Claims that are in pre-bill status and have not been sent to any payer.
33. Rejection reason category — Select this option and then select the rejection reason categories to which this worklist applies. The rejection reason category is a classification system to include specific categories of issue types. Every kick code has one parent rejection reason category, as does every rule.
    Note: To include all rejection reason categories in the worklist, do not select this option.
34. Kickcode — Select this option and then select any kick codes to which this worklist applies.
    Note: To include all kick codes in the worklist, do not select this option.
35. Global claim rule — Select this option and then select the global claim rules to which this worklist applies.
36. Local claim rule — Select this option and then select any local claim rules to which this worklist applies. This field appears only if your practice has set up local rules that result in a HOLD status. This list does not include local formatting rules, which have no bearing on workflow.
37. Custom claim rule — Select this option and then select any custom claim rules to which this worklist applies. This field appears only if your practice has set up custom claim rules.
38. Repopulate all worklists on save — Select this option to repopulate all worklists automatically when you save the current worklist.
39. Click Save.

1. Display the Claim Worklists page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Claim Worklists, click Claim Worklists.
2. Click Edit worklist defaults.
3. Edit the worklist defaults for each worklist using the fields provided.
4. Click Save.

1. Display the Claim Worklists page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Claim Worklists, click Claim Worklists.
2. Click Edit team assignments & priority.
3. Drag and drop each worklist to the desired priority level.
4. Assigned To — Edit the team assignments.
5. Click Save.

 

Before you create claim worklists and teams, athenahealth recommends that you first create a list of current claim management workflows at your practice, noting the individual or team responsible for each workflow. This process will help clarify how custom worklists and teams should best be organized in your practice.

 

If your practice has multiple departments, you can use the worklist instructions and claim note highlighting features. You can add instructions that appear at the top of the Claim Edit and Claim Action pages by entering them on the Claim Worklists page. Using the highlighting feature, you can easily see what you must do to work the claim to remove it from the worklist. This feature is especially helpful when the claim is holding for more than one reason.

 

 

You can create custom filters for use in the Claim Inbox using the Custom Filters page. Custom filters appear along with the defined filters— such as Claim status, Provider group, and Department — in the Claim Attributes section of the Claim Worklists page.

Note: Custom filters created for the Claim Worklists page can also be used in the Report Builder and other reports.

 

Custom filters allow you to report on groups of entities, such as providers and departments, in ways that are meaningful for your practice. For more information, see Custom Filters.

 

 

In the Claim Inbox, the current error is the active hold reason that qualified the claim for that worklist. In the default worklist, the current error is always the most recent kick code applied. Custom worklists can be configured with a kick code or rule filter. These worklists will search all the active hold reasons on the claim and set the current error as the hold reason defined in the worklist configuration. In these worklists, 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.

 

 

If your practice uses an insurance card scanner, athenahealth routes claims with certain eligibility-related denials to CBOHOLD instead of HOLD, and we work the claims for you.

Note: athenahealth also reviews IPN and NEREVIEW denials for claims without an insurance card image (see "Automatic review of claim denials" on the Billing Follow-Up page).

 

 

 

 

 

 

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.