User Guide — Kick Codes, Kick Reasons, and Claim Rules
This page describes kick reasons, kick codes, and claim rules and claim notes.
Kick reasons and kick reason categories
A payer kick reason (also called a denial reason) describes why a claim has not yet been paid or communicates the reason for a change in the status of an unpaid claim.
A denial code is the payer's unique alphanumeric code that identifies the denial reason — the reason that a claim was denied payment. Each payer uses its own set of denial codes to specify the denial reason. Some payers may have more than one set of denial codes: one set for paper format, a different set for electronic format. This makes it extremely difficult to determine the reason that a claim was denied, just by looking at the payer's denial code.
Therefore, for each set of payer denial codes, athenahealth created a "kick reason category" and mapped each payer denial code in the category to a standardized athenaOne kick reason and athenaOne kick code.
An athenaOne kick code is an athenahealth proprietary, unique alphabetic code that identifies a kick reason, regardless of the payer.
Kick reasons are stored in a global athenaOne database. athenaOne displays the athenaOne kick code and kick reason in the Claim Notes section of claim-related athenaOne pages, to make it easier to follow up on claims.
On the Claim Edit and Claim Action pages, practice users and athenahealth staff select kick reasons to enter in the Kick reason field to change the claim status during denial management and claim follow-up. Each kick reason is tied to a claim status; for example, "Invalid CPT code" results in a HOLD status. A warning message appears if you enter a kick code that is not appropriate for the selected status. You can also type a period in the Kick reason field to access the Kick Code Lookup tool. This lookup tool displays only those kick codes that correspond to the claim status selected.
What are claim rules?
Claim rules come from the athenaOne Rules Engine. Claim rules are always shown with AUTO in the User column and SCRUB in the Action column in the Claim Notes section of the Claim Edit, Claim Review, Claim Action, and View Claim History pages.
The claim rule/Business Requirement ID number is listed in brackets after the name (for example, Invalid Name Suffix [BR-006286]). There is also a unique numeric identifier listed in brackets in the Description column.
Note: 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.
Claim rules are designed and built by athenahealth based on payer rules, client input, format rules for claim submission, and previous denials. athenahealth "scrubs" each claim when it is created, and re-scrubs each claim every time it is accessed via the Claim Edit page, and at batch creation.
For more information, see Claim Rules.
What are claim notes?
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).