Worklist: HOLD
Issue: The payer has indicated the member ID on the claim is inaccurate or the patient cannot be identified as the payer's insured on the claim's date of service.
Next Steps: Please scan and upload a copy of the patient's insurance card if available, and review the insurance card image to confirm the member ID. Update the member ID in athenaOne if necessary and resubmit the claim. You may also update the insurance package and resubmit the claim or transfer the balance to patient responsibility.
Corrective actions
- Verify and update patient policy.
- Make necessary corrections and resubmit the claim.
- Transfer the balance to the patient responsibility.
Note: If after acting on this error, the claim remains in a hold status (HOLD or MGRHOLD), the claim requires additional review or work.
- Check patient demographic information.
- If a scanned image of the patient's ID card is present in the policy registration in athenaOne, open it.
- If patient ID cards are not scanned into athenaOne, refer to the patient record on site.
- Review the eligibility detail for correct member information.
- Please contact the patient if there is no copy of the insurance ID available.
- Look for and correct the following possible errors. Make sure to correct demographic errors on both the Update Policy Details page and the Quickview page.
- Member ID/certification number was mistyped on the Update Policy Details page
- Patient was not covered on the date of service of the claim. (The effective and expiration dates are incorrect on the Update Policy Details page.)
Running an updated DOS eligibility check may resolve this error. - Member ID/certification number has a relationship to insured suffix that is missing (for example, 00-self or 01-spouse for some payers) on the Update Policy Details page.
- Member ID/certification number has a BCBS plan prefix that is missing or incorrect (BCBS prefixes are 3 alpha characters for non-federal employee program members, and the prefix is R or federal employee program members) on the Update Policy Details page.
- Other demographic information may be incorrect, such as patient or subscriber's name spelling, DOB, gender, or SSN, causing the payer to not identify the patient as covered (found on the patient's Quickview and the Update Policy Details page).
- Payer requires the patient's group number on the Update Policy Details page.
- If changes are made to the insurance, athenaOne will prompt to determine if the changes should apply to all open claims or only the current claim. Select the appropriate option. Please review and resubmit all claims for this patient.
To resolve from the Claim Action page
To resubmit 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.
- 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.
- Review the claim information.
- Actions — If the claim needs to be resubmitted to the payer, select Add Kick Reason.
- Make any necessary changes to the claim details.
- Kick reason — Enter DRPBILLING.
- Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
- Click Submit.
To transfer the claim balance
- 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.
- Review the claim information.
- Actions — Select Transfer Balance.
- Select the charges that you want to adjust.
- Transfer to — Select Patient or Next Payer.
Note: Both options map to kick reasons, so reporting is unaffected. - Claim note — Enter a claim note to indicate why the balance is being transferred.
- Click Submit. Claims with a balance transferred to Patient are kicked with PTRESP; claims with a balance transferred to Next Payer are kicked with NEXTPAYOR.
To resolve from the Claim Edit page
To resubmit 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.
- On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
- Review the claim notes.
- If athenahealth has researched the denial with the payer, a detailed description is included.
- If there is an EOB or letter from the payer, click the link to review it.
- If further clarification is needed, contact the payer directly.
- Applies to — Select the correct insurance type.
- Status — Select DROP.
- Kick reason — Enter DRPBILLING.
- Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
- Click Save.
To transfer the claim balance
- On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
- Review the claim notes.
- Action Taken/Note Source — Select Generic Note/From Other Source.
- Kick Reason — Select PTRESP.
- Claim Note — Enter a note to indicate why the balance is being transferred to the patient.
- Click Save. A statement will be sent to the patient.
Related Topics
athenaOne — Summer 2024 Release
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