User Guide — Paper Claims
Some payers have custom paper claim forms or requirements for submitting claims that athenahealth cannot support. These claims go into a queue for you to print (or type, or handwrite) and submit.
Paper claim forms
Only a small percentage of claims are printed and mailed to the payer using paper claim forms. If athenahealth submits paper claims for your practice, your claims are automatically submitted on the appropriate paper claim form. For those practices that submit their own paper forms, athenahealth posts the names and dates of payers and transition dates as they become known on the athenaNetwork.
athenahealth is responsible for sending all claims to payers except for claims that have been marked as "Force Drop to Paper — practice." See also: Generate Claims.
If a payer communicates a change that is not listed or has different information from what is published, please contact the CSC by selecting Support > Create Case or Call in the Main Menu.
More information about the CMS-1500 claim form, including the complete instruction manual, is available at www.nucc.org.
Supported claim formats
athenahealth does not guarantee support for any paper claim format other than the CMS-1500 and UB-04. If you need to submit non-CMS-1500 or non-UB-04 paper claims, please provide a sample of the custom forms to your salesperson, who will check whether that format is supported. You are responsible for submitting claims with unsupported formats.
Secondary attachments
You are responsible for printing and submitting secondary or tertiary insurance claims that require documentation other than proof of prior payment. athenahealth submits secondaries that require the primary's EOB, but you must submit secondaries that require operating notes, for example.
Multiple diagnosis codes and pagination
Various payers require use of their proprietary paper forms for submitting claims. Often the amount of information these forms can hold differs from the amount that fits on an electronic claim.
You can enter up to 12 diagnosis codes per claim in athenaOne, but you may come across a paper form that allows only four. athenaOne solves this problem through "pagination," which refers to fitting the information from one claim onto multiple pages.
For example, suppose you have a claim with three procedure codes (we'll call them 1, 2, and 3) that reference eight diagnosis codes (A, B, C ... H). If this claim needs to drop to a CMS-1500 paper form, there are several scenarios that could occur, depending on which diagnosis codes are referenced by which procedure codes. Note that athenaOne puts each charge on the earliest page on which it will fit.
Note: athenaOne automatically reorders charges by RVU (with some exceptions), but this functionality is not affected by pagination. So, if three charges fit on Page 1, they will be ranked by their relative RVU values, and if there are another three charges on Page 2, they will likewise be ranked in order of their relative RVU values.
Pagination scenarios
Scenario 1
CPT 1 points to four diagnosis codes: A, B, C, D
CPT 2 points to one diagnosis code: E
CPT 3 points to four diagnosis codes: E, F, G, H
In this case, CPT 1 goes on Page 1, and because only four diagnosis codes can go on one claim, CPT 2 and 3 go on Page 2.
Scenario 2
CPT 1 points to four diagnosis codes: A, B, G, H
CPT 2 points to diagnosis codes C, D, E, F
CPT 3 points to diagnosis codes G, H
In this case, because CPT 1 and CPT 3 share the same diagnosis codes, they both go on Page 1, and CPT 2 goes on Page 2.
Scenario 3
CPT 1 points to four diagnosis codes: A, B, C, D
CPT 2 points to diagnosis codes E, F, G, H
CPT 3 points to diagnosis code A, B, G,H
In this case, because CPT 1 goes on the first page, CPT 2 goes on the second page, and because CPT 3 doesn't reference a subset of either, it goes on its own third page.