AI-Determined Copay Amount

The following reports reflect whether the copay was collected using the AI-enabled Copay view or the legacy (non-AI) Copay view:

• Time of Service Collections report (Detailed view)
• Time of Service Collections - Cross Practice report (Detailed view)

There is no change to the Summary views of these reports, since the Copay reasons aren't surfaced at this level.

We know many of you have been researching copays manually for years. You’ve checked insurance cards, reviewed eligibility details, and done everything you can to collect the right amount at check-in. That experience matters — and we respect the work that goes into it.

The AI-determined Copay isn’t here to replace your judgment. It’s here to support it.

Instead of relying on a single copay type or a manually entered amount, the AI-determined Copay looks at the full context of the visit — all at once.

• The AI model was trained on large volumes of appointment/payer/provider/eligibility data and finalized claims and is continuously evaluated against adjudicated EOB copay results.
• Most importantly, we only show an AI-determined Copay amount when the system has high confidence that the copay amount meets our accuracy standards. If it’s not confident, it won’t surface an AI-determined Copay amount, and instead, we show the legacy/non-AI copay from the Insurance Policy page.

The goal of AI-determined Copay is to help you collect accurate and timely copays at time of service, and help reduce:

• Under-collection that leads to billing follow-ups

• Over-collection that leads to refunds

• Manual research time at the front desk

Over time, we evaluate the AI-determined copay amounts against adjudicated EOBs to ensure accuracy is maintained.

We appreciate the work you do every day to take care of patients and keep operations running smoothly. AI-determined Copay is meant to make that job easier.

• The AI-determined Copay amount is currently only on the Check-in and Checkout pages. If the Copay amount is AI-determined, you'll see the "DETERMINED BY AI" label.
• The Copay amount on other pages, such as Quickview or the Appointment page, is not yet AI-determined.

• Patient-facing enhanced Self Check-In will display the AI-determined Copay amount if available. If the AI-determined Copay amount is unavailable, the legacy Copay amount will be displayed.

If the AI Copay logic could not determine the copay amount, we will automatically display the legacy (non-AI ) view.

The copays shown on the Insurance Policy page are based on copay types, which are primarily tied to provider specialty and, in some cases, place of service.

• For the Office Visit copay type, there is limited automation.
• For other copay types, the copay amount typically relies on manual entry in order to populate in the TOS payment section.

The AI-determined copay does not rely on copay types from the Insurance Policy page. Instead, it evaluates the full appointment context in real time, including appointment information, provider information, patient insurance (both primary and secondary if available), eligibility information, and more.

Everything that copay types consider (such as specialty or place of service), the AI-determined Copay also considers — along with additional factors. By evaluating these data points together, the AI-determined Copay is designed to provide a more accurate copay amount.

It’s normal for copay responsibility to vary based on the specific details of an appointment.

For example:

• An insurance card may list a standard copay amount, but certain visit types (such as preventive services, depending on payer rules) may result in a $0 copay.

• Even for the same patient and provider, small differences in appointment type, place of service, specialist vs PCP, or payer configuration can result in a different copay outcome.

The AI-determined Copay is trained on historical appointment and adjudicated data and is continuously evaluated against finalized EOB results to ensure accuracy.

If you would like to view copays based on copay types from the Insurance Policy page for a given appointment, you can click the Select copay manually (non-AI) option on the Time-of-Service page.

If your organization or department prefers not to display the AI-determined Copay by default for any appointment, please contact your CSM or the CSC to turn off the Display AI copay by default department setting.

While the AI copay feature supports most family billing scenarios, it does not support family billing for family appointments that fit the following criteria:

• If your practice has the Family Billing Practice Setting enabled,
• AND if the patient has family members registered in athenaOne,
• AND if the family members have same day appointment as the patient,

There is no AI copay determination, and only the legacy Copay workflow is available.

• The "collected toward copay" banner reflects the aggregated collection toward the original due amount.
• You must select a Reason for different copay amount whenever the aggregated collected total does not equal the original Copay due amount.
  • The field disappears when aggregated collections equal the original due amount.
  • The field appears when aggregated collections do not equal the original due amount (either less than or more than the original due amount).

In this example scenario, you collect the $70 copay in multiple payments: