User Guide — Claim Status

This status is used by athenaCollector No Posting and No Follow-Up users only to indicate that the claim had been billed, denied by the payer, and is under appeal by the practice.

Note: athenahealth does not follow up on claims in APPEALED status, so athenaCollector clients should not use this status to request an appeal.

See: To request that athenahealth appeal a claim

This status indicates that the claim is in danger of missing the filing deadline. athenaOne automatically assigns ATHENADROP status to any claim 15 days before the payer's filing deadline, regardless of the claim status. This will only occur if proof of timely filing is not available. Not all payers, however, are included in the timely filing alarm feature. Claims in this status will be submitted to payers in a paper claim format.

After the claim is submitted, the claim reverts to its previous status.

ATHENADROP status is used solely to avoid any loss of revenue because a claim was not submitted within the payer's filing deadline.

Note: To comply with Minnesota Statute §62J.536, athenahealth will not force the electronic submission of Minnesota-based paper claims approaching timely filing limits.

athenahealth recommends that your practice not take any action on claims in this status.

This status indicates that the claim has been submitted to the payer and remittance is expected. The claim remains in BILLED status until a remittance is received from the payer.

athenaOne has an automated "claim alarm" that is triggered if a claim in BILLED status has reached the payer-specific, usual time limit for processing claims. athenahealth determines this time limit for each payer.

athenaOne moves an overdue claim to FOLLOWUP status for athenahealth users to contact the payer. (Does not apply to No Posting and No Follow-Up clients.)

For more information about claim alarms, see the Claim Alarms page.

athenahealth recommends that your practice not take any action on claims in this status.

This status indicates that a payer response received indicates the claim failed the payer adjudication process and requires investigation by an athenahealth user.

Claims that have been requested to be appealed or resubmitted by your practice will also temporarily stay in this status until those actions are completed.

athenahealth recommends that your practice not take any action on claims in this status.

This status indicates that remittance has been received for the claim (or the charge has been adjusted off), there are no outstanding issues, and the claim requires no further action.

This status indicates that the claim contains charges eligible for collections. The charge items associated with the claim are listed on the Collections Worklist page. The minimum outstanding amount required can be set to include a patient's name on the collections list. Once listed and selected, those charges can then be sent to collections.

See also: Managing Collections.

This status indicates that the claim has passed the initial, automated "scrub" by the athenaOne Rules Engine and is ready for submission to the payer.

athenahealth is responsible for submitting a claim in DROP status. In most cases, athenahealth transmits the claim to the payer electronically, on the same night that the claim is assigned the DROP status.

This status indicates that a claim has been submitted to a payer for which remittance is overdue. FOLLOWUP status is triggered by an automatic "claim alarm" in athenaOne (see Claim Alarms page).

athenahealth reviews all claims in FOLLOWUP status and takes appropriate action. This usually means that athenahealth contacts the payer (via Web portal, IVR, or direct calls) to determine the cause of the delay and to take any action necessary to ensure a remittance (payment or denial) from the payer. (Does not apply to No Posting and No Follow-Up users.)

athenahealth recommends that your practice not take any action on claims in this status.

This status indicates that the claim contains errors that are specific to the individual claim and that require information from the patient, chart, or physician to resolve.

athenahealth does not submit a claim in HOLD status to the payer, unless the timely filing deadline is approaching (see ATHENADROP status). The claim remains in the system until the errors are corrected by the practice. HOLD status errors can usually be resolved by looking in the patient chart. These errors include (but are not limited to):

• Demographic errors: Missing address or incorrect date of birth
• Patient insurance errors: ID number is incorrect or patient is not eligible on date of service
• CPT code errors: Procedure code does not match patient sex or age, or procedure code does not match diagnosis code

athenahealth recommends that your practice focus on claims holding with errors in this worklist.

This status indicates that the claim contains an error that typically needs to be resolved by a billing manger or someone who has access to key billing data. MGRHOLD status errors include (but are not limited to):

• Provider Number Missing or Pending: Provider number for the billing provider is either missing from the database, or the provider number is pending review by the athenahealth provider setup department.
• Credentialing issues: Provider number is not correct or is not credentialed with the payer.

athenahealth recommends that your practice focus on claims holding with errors in this worklist.

This status is automatically assigned to all appointments at check-in time. An appointment remains in missing status until charge entry is accomplished, or until the appointment is marked as not requiring charge entry (using the button at the bottom of the Charge Entry tab). This status is used to indicate that services were rendered to a patient for which no charges have been entered (that is, the billing slip/encounter form is missing).

athenaOne maintains a Missing Slips list for each department in the practice to help account for every billing slip. The Missing Slips list can be accessed for each department via the Workflow Dashboard Missing Slips column. It can also be accessed by using the billing slips link at the top of the Today's Appointments worklist or the Missing Slips row in the Inbox on the Non-clinician home page.

athenahealth recommends that practice managers ensure that the Missing Slips column is 0 at the end of each day. If charge entry is handled in batch mode, the Missing Slips list functions as a charge entry batch worklist.

When a claim develops a credit balance, the OVERPYMT kick code is applied and the claim moves to OVERPAID status.

Automated overpayment resolution

Beginning in November 2017, athenahealth intercepts and reviews overpaid claims in HOLD, MGRHOLD, or OVERPAID status sent with any of these kick codes:

• OVERPYMT
• OVERPY1MRY
• OVERPY2NDY
• OVERPYEOBPOST

After reviewing the claim, we either:

• Resolve the overpayment issue on the claim.
• Provide next steps for how you or the payer can resolve the overpayment (we may contact the payer on your behalf to determine the next steps).

When athenahealth is working a claim for overpayment, the kick code OVERPYMTATHENACALLPAYER or OVERPYMTATHENARVW appears in the claim notes within 3 days. These kick codes move the claim to CBOHOLD status.

Note: athenahealth does not resolve overpaid claims with service restrictions that you may have applied or overpaid claims that were already in your worklists prior to your practice's rollout date for this service.

athenahealth may need to send a claim back to you under these circumstances:

• We cannot reach the payer.
• The payer cannot or will not provide us with the necessary information.
• The claim must be voided from the payer's portal.
• You must coordinate benefits with the patient or the patient must do so with the payer.
• A refund check is required to resolve the overpayment with the payer.
• A determination from you is required to accept an overpaid balance.
• You changed something on the claim that caused the overpayment.