User Guide — Real-Time Adjudication

 

To use RTA functionality, you must have one or more of the following roles:

• Receptionist
• Receptionist: Charge Entry
• Receptionist: No Double-Booking
• Practice Superuser

 

For RTA-eligible claims, a link to Submit claim for RTA appears at the bottom of the Claim Edit page. If the link does not appear, the claim is not eligible for RTA.

 

For specific instructions, see Claim Edit.

 

 

RTA is available only for a limited number of payers, including United, Humana, and BCBS-PA Highmark primary claims (athenahealth is working to establish RTA with as many payers as possible).

 

Some claims are not eligible for RTA due to benefit coordination issues or required attachments. Claims that are not eligible for RTA indicate this in the Claim Notes, and the Submit claim for RTA link does not appear.

 

athenahealth uses many criteria to determine which claims are eligible for RTA. Chief among these is whether a particular payer offers RTA. Some of the other criteria athenaOne takes into account are payer-specific, whereas others are global for all payers. Examples include:

• Claims with a secondary insurance. RTA can only determine what the primary payer has calculated they will pay and the patient owes. Because the secondary may pick up a portion of the patient's payment, we want to wait until they have adjudicated the claim as well.
• Payers may sometimes have another entity adjudicate certain plans or products (for example, Medicare fee-for-service plans); in these cases, the claims are considered ineligible.
• Claims with more than X charge lines. Depending on the payer's system, claims with more than X number of charges may be ineligible.
• Claims with multiple days of service.
• Claims with procedures or services that may involve waiting on another entity. For example, procedure 36415 (venipuncture) may require waiting 72 hours for a possible claim from a lab, in which case the 36415 is global.

 

Though the RTA response is not an actual ANSI-standard 835 file, it shows much of the same information. The display is very similar to the athenaOne ERA display, as well as the AREP and the industry standard MREP. However, the buttons along the top are slightly different:

• Collect Payment — Transfers the patient responsibility portion of the claim to the patient and displays the Collect Payment page
• Return to Quickview — Displays the patient Quickview page
• Return to Claim Edit — Displays the Claim Edit page
• Print Real Time Adjudication Notice — Opens your printer dialog box

Beneath these buttons on the left, you see:

• Primary Payor information — The insurance package name and address
• Payee — Your practice's name and address
• Group Legacy Number — The legacy identifier for your medical group
• Group NPI Number — The National Provider Identifier for your medical group

The Adjudication Notice appears next. Different payers return varying amounts of information and detail, so the information displayed here varies by payer. This information could be charge-level, claim-level, or a mix of both, depending on the particular claim.

 

Typically, the Adjudication Notice shows some claim-level data, such as patient and provider information, as well as claim-level estimated dollar amounts. Depending on the payer, this area also displays the estimated allowed amount, estimated billed amount, estimated paid amount, and estimated patient responsibility. The claim ID, primary TCN (that is, the payer's claim ID), and the date also appear here.

 

Some payers return charge-level information, such as Service Dates, CPT code, Units, Billed, Est Allowed/Est Contr, Est Pay/Est Withold, Est Deduct/Est Global, Est Coins/Est Cap, Est Copay/Est Oth CO, Est Other PR/Est Denied, and Reason/Remark. Under this section, Reason/Remark definitions are listed, if returned by the payer.

 

The returned status of claims sent for RTA varies by payer, but the general categories are:

• Payable — The message typically includes claim- or charge-level dollar information. Indicates the payer has received and fully adjudicated the claim.
• Pended — The message typically means the payer has received the claim, but the payer's adjudication system has designated the claim as pending further review before making a final benefit determination.
• Denied — The message typically means that the payer has received the claim, but the payer's adjudication system has denied it. The reason for the denial may or may not be stated in the payer's message.

All possible RTA responses are listed here. Please note that no further action is required by the user, in all cases.

 

RTA Response	Explanation
Payable	The payer has adjudicated the claim as payable.
Pended	The payer has adjudicated the claim as pended. No immediate action is required; final determination will be communicated after payer review.
Denied	The payer has adjudicated the claim as denied.
Submitted but unable to adjudicate in real time	Claim was submitted to the payer but is ineligible for real-time adjudication. No immediate action is required; final determination will be communicated after payer review.
Error claim will be resubmitted as batch	There was an error submitting the claim; athenaOne will resubmit it in the normal batch process.

 

RTA eligible appointment notes appear automatically. No additional setup is required for RTA eligible appointment notes. Not all claims are eligible for real-time adjudication.

 

When a patient checks in, this note reminds you to code and enter charges at the time of service, then submit the claim for RTA and collect any remaining patient balance while the patient is still in the office.

 

RTA eligible appointment notes appear in all places that athenaOne displays appointment notes.

 

 

You can find the Real Time Adjudication Report on the Billing Operations tab of the Report Library. For more information about using the Report Library, please refer to Report Library.

With the Real Time Adjudication Report, you can examine your practice's RTA claims and the associated patient liability. You'll get the most out of RTA when you monitor how effectively your practice uses RTA to collect self-pay dollars while the patient is still in the office.

 

RTA data appears in these columns:

• CLAIMID — The identification number of the claim.
• PATIENTID — The identification number of the patient.
• Service Date — The date on which the service occurred.
• Charge Entry Time — The date and time at which the charge was entered (using 24-hour time format).
• Submission Time — The date and time at which the claim was submitted (using 24-hour time format).
• Result — The result of the RTA transaction.
• Payer — The payer on the claim.
• Payments Before Submission — The amount collected by practice staff before a claim was submitted for RTA. These amounts are typically copays.
• Payments After Submission — The amount collected by practice staff within 30 minutes after a claim was submitted for RTA. These amounts typically represent payments collected as a result of the RTA notice.
• Total Patient Liability — The amount identified as patient responsibility by the payer on the RTA notice.
• Uncollected Patient Liability — This is the Total Patient Liability minus Payments Before Submission and minus Payments After Submission.
• Department — The department on the claim.
• Submitting User — The username of the practice user who submitted the claim. If athenahealth submitted the claim, this field displays "AUTO."