User Guide — Claim Rules

Global rules are written by athenahealth and attached to a benefit package ("insurance package" in athenaOne); global rules are triggered when any practice creates a claim destined for that insurance package. Global rules require payer documentation. Global rules can originate from athenahealth research, athenahealth denial management activity, government mandate (such as HIPAA or NPI), Medicare's Correct Coding Initiative (CCI) edits, or at your request, with supporting documentation.

Predictive rules are overridable and are derived automatically from denial trends from all claims in athenaOne. If you override a predictive rule, you can choose to submit the claim anyway but adjust off the balance (because you don't expect payment).

Posting rules are written by athenahealth to allow more accurate transaction and denial posting. athenahealth normally posts according to the remittance information; however, in some situations, a literal interpretation of the remittance data will lead to inaccurate posting. A posting rule overrides the literal interpretation so that the correct transaction or denial is reflected on the claim.

Local rules are requested by you and written by athenahealth, if the request is deemed by athenahealth to be legally and contractually compliant. A rule is made local in scope when there is not sufficient documentation to support it being global. Sometimes athenahealth promotes one or more of your local rules to global rules.

athenaOne allows users in your practice who have the Billing Admin: Custom Rules user permission to create custom claim rules for these specific circumstances: 

• Procedures that require modifiers
• Procedures that require authorizations/referrals
• Procedures that require coding review
• Procedures with invalid diagnosis codes
• Procedures with invalid modifiers
• Non-billable procedures

Custom rules can act only to move claims into HOLD or MGRHOLD. They can be made overridable and are based on a limited set of parameters.

Because you specify the conditions of these custom rules, they do not go through our normal testing process. Therefore, it is possible to create conflicts with global rules in the athenaOne Rules Engine. Because a great deal of research goes into our Rules development process, we do not override global rules if such a conflict exists unless written documentation from the payer can be provided to update the logic within a specific global rule.

About custom rules

You can create custom rules to review claims for general completeness and accuracy, but you should use caution if you create custom rules. To avoid unnecessary holds on claims, make sure that you create rules with the narrowest scope possible and with clear instructions. Following are our recommendations for custom rules:

• Instead of creating a custom rule for a payer requirement not covered by a global rule, create a support case so that we can scope a global rule. On the Main Menu, click Support and then click Create Case or Call.
• Make sure that only a trained, designated person or small team at your practice creates and monitors your custom rules.
• Review your custom rules quarterly to determine whether you can delete rules or conditions that no longer apply.
• If a potential athenaCollector feature could eliminate your need for a custom rule, please visit the Ideas page of the Success Community.

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).

If a rule has been migrated to the new Billing Rules system (or is a new rule added only in the new Billing Rules system), you'll see a Business Requirement ID (BR-######) instead of a legacy Rule ID.

• Local rules will display as [Local BR-######].
• Click the information icon to see details about the BR ID:
  • If this was a migrated legacy rule, you'll see the legacy Rule ID and the new BR ID.
  • If the rule was created only in the new Billing Rules system, the information icon message will not have any legacy Rule ID.
  • Click View BR ID Search to see the mapping of legacy Rule IDs to BR IDs for migrated rules in your practice.