User Guide — Claim Alarms

 

Billed claim alarms identify the optimal time to contact payers about missing remittance. athenahealth uses these alarms to identify missing remittance for you and effectively follow up on missing information. The length of a billed claim alarm varies from claim to claim and is determined by factors specific to the claim, including the payer, practice, and provider.

 

athenahealth uses machine learning technology for billed claim alarms to calculate and set alarms to the most effective time for follow-up.

Note: Machine learning technology applies only to billed claim alarms.

 

Billed claim alarms evaluate claims individually, enabling athenahealth to consider more billing scenarios based on client-specific and network trends. In this way, we ensure that follow-up on a claim results in meaningful action.

 

 

Kick code alarms are analyzed monthly, taking into account the transfer type, as well as the insurance package and IRC remittance information. Kick codes are assigned to claims in a number of ways:

• By athenahealth or by the practice — Kick codes are selected based on information gathered during the follow-up process.
• By EOB/ERA — Kick codes can be assigned based on many factors, including a payer letter acknowledging receipt of the claim and other claim-specific information. The selected kick code may result in an alarm adjustment based on the information provided by the payer.
• By CSI (claim status inquiry) — Kick codes can be assigned based on an automatic transmission of information between athenaOne and a payer. Occasionally, the assigned kick code is noted on the claim and does not extend the alarm length (for example, the INFORM kick code does not extend the alarm length).

If an alarm is associated with a kick code, the claim's billed claim alarm is cleared and replaced by the kick code alarm. This action can cause the alarm to extend beyond the original BILLED alarm date.

Tip: When you want to add a note to a claim without extending its alarm, the best kick code to choose is INFORM.

 

Important: When anyone — athenahealth or practice user — makes an adjustment to a claim, a new alarm may be assigned. For this reason, please be careful when using kick codes; alarm lengths may be unintentionally increased.

 

For example, if a claim is assigned a 60-day alarm and a practice user edits the claim at day 50 to add a note that the claim is in process (CIP), the original 60-day BILLED alarm is cleared and replaced with a 30-day CIP alarm. If the practice user selected the CIP kick code without adding any supporting information, the claim — which would have been in FOLLOWUP status at day 60 — will not be moved to FOLLOWUP until day 80.

 

 

Timely filing alarms are set automatically when you create a claim. Timely filing logic applies only to initial claim filings. There are also payer-imposed timely filing limits associated with denials and appeals that athenaOne does not account for in the timely filing alarms. Payer-imposed timely filing limits vary by payer, starting point (from original DOS, from date on denial letter, from date of crossover), and occasionally by contractual agreement.

Note: You can run the Timely Filing report to locate unbilled claims that are nearing their timely filing limit. This report helps you ensure that claims do not miss payer filing deadlines and that your practice is not missing out on payment for your services.

 

If a claim is within 15 days of its timely filing limit and has not entered a BILLED status:

• A timely filing alarm fires on the claim (regardless of its state of completion).
• The claim is dropped to the payer on paper to make sure that the claim is on file with the payer (even though the claim is not in a condition to be paid).

After the drop action, the claim is immediately routed to your MGRHOLD bucket for further work and, therefore, never triggers a billed claim alarm.

 

Timely filing alarms are based on the insurance payer selected. Each claim's timely filing limit can be seen on the Phone Payer Information page for the specific claim. You can access the Phone Payer Information page from the Claim Action and Claim Edit pages.

 

Note: If your practice has contracted with a payer for a shortened or extended timely filing rule, please provide documentation that references the contracted filing limit in a support case so that a practice-specific alarm can be created. To open a new support case, contact the CSC by selecting Support > Create Case or Call in the Main Menu.