User Guide — Wrap Claim Billing

To identify the need to wrap bill, and to bill accurately, athenahealth must be aware of your contracted wrap payers, and the patient must be enrolled with both a replacement plan and Medicare or Medicaid.

athenahealth requests that, as a best practice, your organization allow the athenaOne system and logic to work as intended. Please do not void or delete a split claim. When a split claim is voided or deleted, athenaOne does not send the claim to the government payer for balance payment.

We also recommend that your office staff not make any updates or changes to insurance packages. When such changes occur, payers inadvertently receive multiple claims, resulting in duplicate denials or denied charge lines.

To submit wrap claims, athenahealth must be aware of your most recent payer contracts.

Please contact your CSM if you would like additional resources about specific states and payers.

The wrap claim billing process can be handled on the same claim or on two separate claims. Wrap claims can be identified by details in the Claim Notes, such as a global wrap rule or the kick code WRAPPOSTINGNEXTPAYOR:NEXTPAYOR.

Claims may also have been billed with CPT T1015,SE.

Claims that are submitted to Medi-Cal for RHC and FQHC services may include a proof of Medicare denial in the form of an Explanation of Medicare Benefit (EOMB).

1. Claims must first be submitted to the patient's Medicare or Medicaid Replacement plan.
   If the replacement plan's contract rate is less than that of the related government payer's contract, that government payer pays the difference.
2. When Medicaid or Medicare requires the initial Explanation of Benefits (EOB), athenahealth uses a single claim to submit the claim to both parties. When Medicare or Medicaid does not require a copy of the other payer's EOB, we create a second claim and submit both claims simultaneously.

When a denial is received related to Coordination of Benefits, athenahealth runs an eligibility check for the patient on the claim. Based on the eligibility response, the next best action to resolve the denial is taken and the claim is resubmitted.

When a denial is received for any other reason, athenahealth staff work to resolve the denial using all available resources, including moving the claim to your work queue if action on your part is required. If applicable, athenahealth resubmits the claim to the existing patient insurance packages listed on the claim.

Note: Updating of patient insurance packages on wrap claims is not part of the athenahealth workflow. If you do see this occurring on claims, please create a support case to have feedback provided to the appropriate teams (Billing & Claims > Correct/Resubmit Claims).