User Guide — Managing Insurance Packages
athenahealth maintains a global database of insurance packages for use by all athenaOne practices. As our network grows, we add new payers and we maintain accurate information for each payer in the database, so you don't have to. You can request that we add a new payer or insurance plan to our database via the Insurance Package Requests page. Requests to add new insurance packages are acted on in a reasonable time frame.
Rules for insurance packages
Our athenaOne Rules Engine is updated daily, based on our own research and from information we may receive from you. Everything we learn about every payer is captured and is made instantly available to all athenaOne practices. That is the power of athenaOne.
Global 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
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).
Local rules
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.
Custom rules
Custom claim rules are configured by users who have the Billing Admin: Custom Rules user permission. 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. You are responsible for maintaining the custom rules that you create.
Custom claim rules for specific insurance packages
For the following common situations, you can create custom rules for specific insurance packages with start and end dates: