User Guide — Credit Balance Processing

To understand the credit balance processing workflow (refunds and takebacks), you need to understand the following:

• Approving insurance refunds (Approve Insurance Refunds page, Issue Insurance Refunds Worklist, and Refund Checks In Process page and worklist)
• Processing overpayments (takebacks, refunds, and unclaimed payments)
• Tracking payments from multiple payers (COB issues)

See the Insurance Refunds Workflow page to learn the step-by-step process for issuing insurance refunds to payers and patients.

You can use the Billing Worklists page to generate a worklist of claims in OVERPAID status.

On the Approve Insurance Refunds page, you can use the filters provided to generate the Issue Insurance Refunds Worklist. The worklist appears in the Task Bar.

The Issue Insurance Refunds Worklist provides a single place to find all requests for insurance refunds. Claims appear on this list if they are in MGRHOLD status and have an active kick code of REFUND. When athenahealth posts for clients, we use this code for paid claims that are later denied. We also use this code when researching overpaid claims for our clients.

The Issue Insurance Refunds Worklist is populated by claims with active REFUND claim notes. It has the usual filters and options. Choosing the worklist gives you the ability to review each item in detail using the Issue Insurance Refund page. This page shows the affected charges with their transaction histories, and provides fields for recording payment amounts and check numbers.

Many practices have multi-step processes for issuing refunds — a billing manager reviews the accounts and approves refunds, but checks are issued separately. If your practice has such an approach, athenahealth recommends using a printed or CSV list to track the approval and check-writing process, then use the worklist to apply the refunds. This process ensures that the transaction post dates of the refunds will match the issue dates of the checks.

Alternatively, your practice can approve refunds by entering the check amount on the Issue Insurance Refund page, while leaving the check number blank. These transactions populate the Refunds in Process worklist.

When a claim develops a credit balance, the OVERPYMT kick code is applied and the claim moves to OVERPAID status. Your practice should review the claim and investigate whether a payer intends to recover the funds and then determine the appropriate response. One of three outcomes is possible:

• Refund
• Takeback
• Unclaimed payment

Note: You can use the Billing Worklists page to generate a worklist of claims in 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.

Overpayment kick codes that require action on your part

 

You are responsible for working claims with insurance credit balances (overpayments) that appear in OVERPAID status. This work includes contacting the payer, reviewing EOBs, and initiating takebacks or refunds. athenahealth applies the following kick codes when an overpaid claim requires action from you.

Kick Code	Status	Action
ACCEPTOVERPYMT	MGRHOLD	You can keep the remaining payment due to payer or allowable verification.
CLAIMCHANGEAFTERBILL	OVERPAID	You changed information on the claim after the claim was billed. You need to review and confirm the information you changed on the claim, and refund the overpayment because it was made based on the original claim. If necessary, re-bill the claim with the updates.
OVERPAYCOB	OVERPAID	You need to review the coordination of benefits (COB).
OVERPYMTPRACRVW	MGRHOLD	You need to take an additional action, as described in the claim notes.
PORTALTAKEBACK	OVERPAID	You need to go to the payer Web portal and void the charge.
SENDREFUND	MGRHOLD	You need to refund the overpayment.
SENDREFUNDINTEREST	MGRHOLD	You need to refund the overpayment with interest.
UNVERIFIABLEBALPRAC	MGRHOLD	You posted the payment without remittance attached. You need to review the claim to see if you should void the payment or issue a refund.

 

The REFUND kick code is used to indicate that the payer wants a refund. The REFUND kick code moves the claim to MGRHOLD status. It also places the claim on the new Approve Insurance Refunds list.

athenahealth will use the REFUND kick code and assign the claim to MGRHOLD status.

The practice or billing administrator then reviews claim in MGRHOLD status using the Approve Insurance Refunds list. Then practice or billing administrator can either:

• Create the printable (CSV) worklist to approve refunds, then use the worklist to enter check amount and check number, and apply the REFUND transaction, which closes the claim (see Approve Insurance Refunds)

• Use the worklist to enter the check amount and apply the REFUND transaction; issue the refund from the Refunds in Process page and enter the check number from there

The TAKEBACKREQUEST kick code indicates that the payer wants to recoup funds on a future remittance. This assigns the claim to BILLED status with a six-month alarm.

athenahealth will use the TAKEBACKREQUEST kick code, which assigns the claim to BILLED status with a six-month alarm.

• If a takeback is received within six months, athenahealth will post the takeback close the claim. athenaCollector (No Posting) clients are responsible for posting their own remittance.
• If the takeback is not received within six months, the alarm fires to NORESPTAKEBACKREQUEST, which goes to OVERPAID status. At this point you can review the claim for a voluntary refund, or you can apply the ABANDONED kick code to close the claim.

Note: Billing managers should carefully follow any abandoned property laws in their state.

The UNCLAIMEDOVERPAY kick code is used to indicate that a payer does not wish to recoup the overpayment. athenahealth will apply the UNCLAIMEDOVERPAY kick code, which assigns MGRHOLD status to the claim. You can then use the ABANDONED kick code to close the claim, with a negative adjustment for reason OTHER.

Note: Billing Managers should carefully follow any abandoned property laws in their state.

You can use athenaOne to track claims that were billed to multiple payers during the billing process. This applies both to claim notes and to transactions.

• On the Claim Review, Claim Action, and Claim Edit pages, the "Kick/Scrub/Notes" column in the Claim Notes section displays the payer associated with the claim note if there are/were multiple payers. (If the payer for whom the note was recorded is still the current payer, the payer name does not appear.)
• The Patient Insurance list on the Post Payment page gives you the ability to record remittance from a payer that is not "current."