User Guide — Claim Worklists Feature

 

Pending claims removes them from the worklist's assignable claims for a specified number of business days. Pending records can be useful when an action must take place outside athenaOne before billing staff can take the next step on a claim.

 

Examples of outside actions include:

• A patient or payer needs to return a phone call.
• A form must be sent or completed.

At the end of the pend period, athenaOne returns the records to either the user who pended them or to the worklist's assignable claims, where any member of the team can work the claim.

 

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 for an existing worklist, or click add new.
3. Pend claims for — Defaults to three business days for all existing and new worklists; edit as necessary.
4. Return pended claims to user — Defaults to Yes (pended claims return to the user who pended them). Deselect this option to return pended claims to an unassigned status.
5. Click Save.

1. Display the Claim Worklist Dashboard: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Click My Worklist. The Default Worklist and all the worklists of which you are a member appear in the Workspace.
   Note: Users with the Custom Claim Worklists: Access All Worklists role, such as billing managers, see all worklists for your practice.

2. Under My Claims, click pend next to the claim.

3. Pend for — Enter the number of business days the claim will not be assignable.

4. Return to me — Leave the box unchecked to return the claim to the worklist's assignable claims immediately when the pend period elapses. Check the box for athenaOne to return the claim to your worklist when the pend period elapses.
   Note: If you do not work or re-pend the claim immediately after it returns to your worklist, athenaOne sends the claim to the worklist's assignable claims list via an overnight script.

5. Enter any notes in the text box.

6. Click Pend.
   The claim moves from your list of assigned records and appears under My Pended Claims, in case you need to refer to or work the claim before the pend period elapses.
   Note: The claim is now counted in the Pended Claims column on your Claim Worklist Dashboard page and also appears in the Assigned to me column as a pended record.

1. Display the Claim Worklist Dashboard: On the Main Menu, click Claims > Claims Worklists. The View Claims Worklists appear in the Task Bar, with links to worklist categories. Click My Worklist. The Default Worklist and all the worklists of which you are a member appear in the Workspace.
   Note: Users with the Custom Claim Worklists: Access All Worklists role, such as billing managers, see all worklists for your practice.
2. Pended Claims — Click a linked number.
   The pended claims appear below it.
3. Review the claims. Click the X icon at the upper right to close, or:
   1. Click un-pend to move the record out of pend status and either return it to the user who pended it or return it to the worklist's assignable claims, depending on whether or not the user who originally pended the claim checked the Return to me box.
   2. Click assign to me to move the record out of pend status and add it to your list of assigned claims.
   3. Click assign to me and go to claim to move the record out of pend status, add it to your list of assigned claims, and display the Claim Edit page for you to review and work the claim.
4. Click Save.

 

athenahealth recommends that you first create a list of current claim management workflows at your practice. This list should include the individual or team responsible for each workflow. You can create teams and worklists independently, as they are not predicated on each other in athenaOne.

 

Your practice administrator should assign the following user roles to the appropriate personnel in your practice:

• Claim Worklists: Admin — Grant this role to billing administrators who will create and manage teams and worklists. Users with this role can access the Claim Worklist Teams page and the Claim Worklists page.
• Claim Worklists: Access All Worklists — Grant this role only to billing supervisors or superusers who need visibility into all of accounts receivable (AR). Users with this role can access the Claim Worklist Dashboard, the Claim Worklist Teams page, and the Claim Worklists page. Users with this role are assigned escalated claims if they are available in a specific worklist. These users can de-escalate a claim or assign it directly to another user.
• Claim Worklists: Productivity Reporting — Grant this role to users, administrators, and supervisors who need visibility into productivity and management of claim worklists. To see the Reporting tab, you must grant this role in conjunction with either the Claim Worklists: Access All Worklists role or the Claim Worklists: Work Claims role.
• Claim Worklists: Work Claims — Grant this role to users who edit claims as part of their daily work. Their usernames will appear in the list of eligible users (by practice) on the Claim Worklist Teams page. Users granted this role can access the Claim Worklist Dashboard and escalate claims out of their worklists. If a user is also a team lead, that user is assigned escalated claims.
• Claim Worklists: Manager Access — Grant this role to billing managers responsible for managing billing staff or billing work. Users granted this role can access the following advanced Claim Inbox features:
• View the Claim Worklists and Escalations tabs.
• View all pended and escalated claims in their worklists (the default filter options show claims pended and escalated by that user).
• Escalate claims to any user.
• View and assign all claims in hold (feature available only to users with the Claim Worklists: Manager Access role or permission).
• Reassign claims to users (feature available only to users with the Claim Worklists: Manager Access role or permission).
• Apply kick codes to claims (feature available only to users with the Claim Worklists: Manager Access role or permission).

Note: Team leads can view, work, de-escalate, and reassign any pended and escalated claims in their team worklists, in addition to working their own assigned claims.

 

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

The Custom Claim Worklist feature is not a solution in and of itself that will solve all AR problems. It is a set of tools that, when combined with best practice workflows, will provide improved visibility into the state of current AR for any practice.