Quick Reference — To correct AUTH claims

1. Click the Authorization menu and look for an authorization/referral for the service provided in this claim.
   1. If found, select the authorization from the Authorization menu, then follow the steps at the bottom of this page to resubmit the claim.
   2. If not found, and the payer is looking for a referral or for an authorization number, confirm who the patient's primary care physician was on the date of service. Call the payer directly, or click the Perform Eligibility check link on the patient's Quickview page.

2. Contact the PCP's office and obtain a referral number or prior authorization number.
   1. Tip for referrals: When available, if future visits/services are known, it is best to request that the referral cover more than one visit.
   2. Note for authorizations: These types of authorization numbers are typically issued before services are provided; however, some payers allow a period after the service date for authorization as well.

3. Add the new number
   1. On the Claim Edit page, select Add new from the Authorization menu.
   2. Enter all the available information in the new Authorization fields.

4. Follow the steps to resubmit the claim.

With some payers, such as state Medicaid plans, a "referral number" is not an authorization number issued by the payer; rather it is the patient's PCP provider number. Unlike the referral/prior authorization numbers we saw in our above cases, the referral number is not unique to the authorized service.

For this type of referral number, athenahealth will look at the Referring Provider field on the Claim Edit page.

1. Check the patient's eligibility for the date of service. Check eligibility by either calling the payer directly or using the athenaOne check eligibility link on the patient's Quickview page.
2. Confirm the name of the primary care physician that the payer has listed for the patient. For some payers, this information is available in the athenaOne eligibility messages.
3. Contact the PCP and obtain a referral number.
4. On the Claim Edit page, click the choose/view link to access the Referring Provider Lookup tool.
   1. If the PCP is missing, click the add new referring provider link and add the referring provider's information.
   2. If the PCP is found in the list, click the select link to populate the Referring Provider field.

5. Follow the steps to resubmit the claim.

1. Confirm that the referring provider currently listed on the claim matches the provider that the payer has on record as the patient's PCP.
   1. Check the patient's eligibility for the date of service. Check eligibility by either calling the payer directly or using the athenaOne check eligibility link on the patient's Quickview page.
   2. Confirm the name of the primary care physician that the payer has listed for the patient. For some payers, this information is available in the athenaOne eligibility messages.
      Note: The PCP number identifies the entity listed as the PCP. Therefore, if the payer has the PCP's office name listed as the patient's PCP, then you must use the medical group number of the provider's medical group (practice).

2. If the PCP information does not match, contact the PCP listed by the payer, obtain a referral for the date of service, and update the PCP.
3. On the Claim Edit page, click the choose/view link to access the Referring Provider Lookup tool.
   1. If the PCP is missing, click the add new referring provider link and add the referring provider's information. See the Referring Provider Lookup page for detailed instructions.
   2. If the PCP is found in the list, click the select link to populate the Referring provider field.

4. Follow the steps to resubmit a claim.

1. Determine whether the referring provider information was updated or changed recently.
   1. On the Claim Edit page, in the middle of the page, click the show voided transaction & full audit history link.
   2. Review the audit history to see if any changes were made to the referring provider.
   3. If changes were made to the referring provider, determine whether the claim was resubmitted since the change.

2. If the referring provider was updated recently and there have been no additional denials from the submission.
   1. Applies to — Select the insurance on the claim for which the kick should apply to.
   2. Status — Select BILLED.
   3. Kick Reason — Enter CIP.
   4. Claim Note — Enter a detail note that tells future viewers of this claim what actions have just been taken.
   5. Click Save Claim.

Note: At least one change must be made to the claim before it can be resubmitted. It is not compliant to resubmit a claim without changes only to see whether the claim will be paid if you resubmit it to the payer.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information.
3. Actions — If the claim needs to be resubmitted to the payer, select Add Kick Reason.
4. Make any necessary changes to the claim details.
5. Kick reason — Enter DRPBILLING.
6. Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
7. Click Submit.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information and existing documentation.
3. Actions — Select Resubmit to Payer from the menu.
   The Resubmission request page appears.
   Note: You can only submit one resubmission request at a time. If you have an on-going request, you cannot access the resubmission workflow until the pending one is resolved.
4. Applies to — Select the payer whose denial you are appealing: Primary Insurance or Secondary Insurance.
5. Resubmission type — Select a resubmission type from the menu.
6. Under Optional information, enter the following information if applicable for your resubmission request:
   1. Documents — Select medical documents or upload a new attachment to expand the section. Select the type of documentation to add. This documentation should support your appeal.
      Notes:
      • Documents that are already attached to the claim appear in the Existing Attachments section. These documents are available for athenahealth teams to use when constructing a resubmission, and do not need to be reattached via this workflow.
      • You can upload only one document via the resubmission workflow. To upload multiple documents, please complete that workflow on the claim itself before coming to this page. Uploading the documents prior to completing the new resubmission workflow allows those documents to be part of the documentation that athenahealth teams select from.
      • The Attachment type field sets the type of document you are attaching; it does not filter the medical documentation check boxes located in the Documents section.
   2. Mail-to address — Click Choose a mail-to address to expand the section. If you don’t see the appropriate address, click add a new mail-to address and enter a new address.
      Best practice: To look for additional addresses, search for the address in the Find address field.
   3. Reason for resubmission — Enter the reason for resubmitting the claim.
      Note: This field has a 2000-character limit.
   4. Claim note — Click Include claim note (internal) to expand the section. Enter any internal notes for your athenaOne practice users. Describe the reasons why the claim should be appealed, list facts to support the appeal, and indicate whether you attached any supporting documentation or faxed any documentation to athenahealth (you may want to do so).
7. Click Submit request. This action applies the PLSPPEAL kick code and moves the claim to athenahealth to review for payer-specific requirements.
   A message appears indicating that the resubmission was successfully submitted to athenahealth.
   Important: We've built automation for highly predictable resubmission scenarios: When the claim is kicked with PLSAPPEAL, athenaOne automatically executes a resubmission based on the appropriate scenario. (We’re actively building tools that limit the effects of this automation by resubmission type. If you disagree with athenaOne’s automation for the resubmission, submit a case via the Success Community: Main Menu > Support > Create Case or Call > Billing & Claims > Correct/Resubmit Claim > Create Online Case.)
   Internal note: If a case team identifies a vetted update opportunity where CRR resubmission automation is confirmed by case team members to be submitting against payer guidelines, the case team member should follow their typical process for triage/issue escalation.
   Best Practice: Case teams must confirm the payer guidelines, and complete any necessary research, prior to moving forward with the escalation.
8. An address validation window may appear if the address you entered could not be verified. Choose the address you want to use by selecting either Correct Address or You Entered, and then Confirm address.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information.
3. Actions — If the claim requires a balance adjustment, select Adjust Balance.
4. Applies to — Select the payer to which the adjustment applies.
5. Charges — Select the charges that need to be adjusted.
6. Reason — Select the reason for the adjustment.
   Note: Each adjustment reason maps to a kick reason, so that reports are unaffected.
7. Custom transaction code (Optional) — Enter a custom transaction code or enter a period to access the lookup tool.
8. Claim note — Enter a claim note explaining why the charges are to be adjusted off the claim.
9. Click Submit. This action closes the claim.

Note: At least one change must be made to the claim before it can be resubmitted. It is not compliant to resubmit a claim without changes only to see whether the claim will be paid if you resubmit it to the payer.

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Review the claim notes.
   1. If athenahealth has researched the denial with the payer, a detailed description is included.
   2. If there is an EOB or letter from the payer, click the link to review it.
3. If further clarification is needed, contact the payer directly.
4. Applies to — Select the correct insurance type.
5. Status — Select DROP.
6. Kick reason — Enter DRPBILLING.
7. Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
8. Click Save.

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Review the claim notes.
   1. If athenahealth has researched the denial with the payer, a detailed description of the documentation requested by the payer is included.
   2. If there is an EOB or letter from the payer, click the link to review.

3. If further clarification is needed, contact the payer directly.
4. Click Edit on the Attachment placeholder.
5. Type — Select the type of documentation being added to the claim.
6. Source — Select athenaClinicals document to attach a document from the patient's chart, or select Upload file to attach a file from your local computer.
7. Documents — Select the appropriate attachment from the list provided.
8. Attachment Note — Enter a note describing the attached document.
9. Click Save.
10. Scroll down to Add Note section.

In the Add Note section

11. Applies to — Select the correct insurance type.
12. Status — Select DROP.
13. Kick reason — Enter PLSAPPEAL.
14. Claim Note — Enter a note to indicate what has been attached and why an appeal of the payer's decision is requested.

If a placeholder for documentation exists in the claim, the placeholder prevents the claim from being dropped after being kicked with PLSAPPEAL, and the claim remains in HOLD status. If you believe that the requested documentation has already been sent to the payer or is not required, you can remove the attachment placeholder.

1. On the Claim Edit page, click Edit on the Attachment placeholder.
2. Attachment required — Select No, and then select a reason why the attachment is not needed.
3. Click Save. The placeholder row is updated. The attachment note changes from [Attachment Required] to [Attachment Not Required].

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Action Taken — Select From EOB.
3. Kick Reason — Enter CONTRACT.
4. Claim Note — Enter a note explaining why the charges are to be adjusted off the claim.
5. Click Save. The charges indicated will close with adjustment reason CONTRACTUAL.