The Avea Way: Best Practices for Billers

  • Updated

Objective

As a member of the billing team, your primary goal is to ensure services rendered to the patient are accurately marked in Attendance and created into new or corrected claims for clean and timely submission to the payer. Meeting your goal will facilitate the shortest time to payment, reliable revenue projections, and set the collections team up for success when performing claim follow-up and claim auditing functions.

Responsible

Billers are responsible for marking attendance and submitting treatments to billing for new claim creation. If part of a larger billing team, additional duties include ensuring timely changes to claim data in order to create corrected claims and managing the rejections queue and workflow.

Billing Team Leads are responsible for selecting the appropriate treatments for claim creation, ensuring the quality of the data on new and corrected claims before submitting claims for processing on to the payer and supporting your team with admin-level configuration changes.

Team Leads will also serve as subject matter experts in their particular department/area and ensure process adherence, working closely with the Billing Managers to surface day-to-day challenges and suggest modifications to the Avea configuration based on their own experiences and the experiences of their team. 

 

Steps for claim creation, claim QA, claim submission and admin-level configuration may be performed by the same individual(s) depending on the organization of your team and user permissions.

 

Process Overview

 

Daily 

Weekly

Billers

Kicking off the billing cycle

  • Marking treatments in the Attendance calendar

 

Working Rejections and Corrections

  • Reviewing and managing claim rejections
  • Reviewing and resolving claim corrections

Pushing new services toward claim creation

  • Submitting Treatments to Billing

Billing Team Leads

Review Management Center Claim Submission tiles

  • Patients with Claim Corrections Pending

  • Claims Rejected - Pending Review

  • Claims Ready for Review/Submit

 

Resolving and Submitting Corrected Claims

  • Aiding your Billers with configuration changes to generate corrections

  • Reviewing corrected claims in the Submit queue

  • Submitting corrected claims

New Claim Creation and Submission

  • Review Patients with New Claims Pending tile

  • QA unsubmitted treatments

  • Creating claims from submitted treatments

  • Reviewing and Submitting new claims

Productivity

  • Ensuring Management Center Claim Submission Tiles are regularly worked to green

  • Weekly Retro of Rejections and Denials

  • Claim Submission Report

 

Billers

Daily Task: Kicking off the billing cycle

Marking treatments in the Attendance Calendar on a daily basis ensures you are setting yourself and your team up for quicker review and submission to billing for claim creation at the end of the week and gives you more time each day to address corrections and rejections that could be holding up processing of already submitted claims.

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Tip: Review the EHR/EMR daily and download a report to import attendance in AveaOffice. This can also give you an opportunity to ensure clinician notes are complete for accurate billing and time to kick treatment notes back to the clinician for edits if needed.

 

Step

Action

Tips and Notes

Navigating the Attendance Calendar

Go to the Attendance tab, located on the left side of the navigation bar below Patients

  • The Attendance calendar defaults to the current week. Be sure the correct week is displayed before adding treatments.

  • Use the Filter by Payer drop down to only display patients who have the selected payer entered as the behavioral payer in their insurance set. This can allow for quicker billing by known payer conditions.

Mark UR-required services

Auto-Fill: Click the Auto-fill link below the patient’s name to add a UR planned service to each available day in the calendar.

  • Use the Auto-Fill link to check the UR plan’s authorization status and save time adding services. If a single date is not needed, simply remove it.
  • Escalate any questions you make have about auth status to the UR manager and/or team lead.

Mark Standalone Services

Click the dropdown on the patient’s row below the appropriate date to create a standalone service or combined service set.

  • The facility you choose will dictate what services are available to bill.

  • Add ICD codes in the order they should display on the claim, with Admitting code first.

 

Daily Task: Working Rejections and Corrections

Ensuring claims are accurate and processing with the payer is a central part of the billing workflow. While rejections and corrections may often be quick to resolve, they may also require escalation to a team lead or billing manager, UR manager or AveaOffice Support. It is important they are reviewed and addressed daily to ensure quick resubmission as lingering rejections or corrections delay payment.

Properly managing the workflow of resubmitting rejected or corrected claims also sets up your team members, leads and managers for success as Claim Notes added and Issues tagged during this process give context to the problems that impacted processing.

Rejections

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Step

Action

Tips and Notes

Reviewing rejections

Go to Work Center > Insurance Claims > Currently Rejected/Held Claims

Sort the list by payer or patient, and investigate the rejection reason by reviewing the claim’s Processing Events

  • Claim Rejected by Payer is a rejection message sent from the Payer’s system.

  • Claim Rejected by First/Second Edits is a rejection message sent from the clearinghouse.

  • A Held claim is not rejected, instead, it is held by the payer for processing often for needing additional documentation.

  • The Details column under the Processing Events tab will cite the exact reason the claim is rejected.

Addressing the reason for the rejection

  • Make changes you are permitted to make in AveaOffice to fix the claim

  • Escalate to UR Manager for UR plan edits

  • Escalate to Team Lead for admin-level setting changes

  • Escalate to AveaOffice Support when rejection details are unclear

  • Common rejections and how to resolve them are documented in the Help Center

  • Depending on your level of permission, you may need the help of other team members to make changes to UR plans or other billing information.

Add notes to the claim

Go to the Notes sub-tab in the claim’s Work Claim tab and click Create Claim Note

Create a follow-up instance of the claim: No Changes

or

Create a follow-up instance of the claim: Correction

When no change to the claim’s data was needed:

  • Go to Patient’s Name > Insurance Billing > Claims and click on the Resubmit link next to the claim ID.

or

When data on the claim was changed to address the rejection reason:

  • Go to Patient’s Name > Insurance Billing > Review Corrections and click on the Check for Corrections button, then confirm.

 

  • It’s important you choose the best Issue Source and Issue Type when resubmitting a claim with No Changes or resolving a correction, as it adds context for your team to understand the issues that have affected the claim.
    If the correct Issue is not available, ask your Team Lead or Billing Manager to create the appropriate Issue for you to select.

 

 

Corrections

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Step

Action

Tips and Notes

Reviewing Corrections

Go to Work Center > Insurance Claims > Create Corrected Claims

Sort the list by Patient and note the type of correction.

Click on the Compare link to view what data on the claim is changing

  • When comparing data, give special attention to the red highlighted lines.

  • If a claim ID on a correction line is prefaced by [New] from Claim ID, then a claim split has occurred to move dates of service away from the original claim to a New claim.
    You must resolve both claim lines to complete the workflow.

Resolving corrections

Click the Resolve link on the claim correction line to open the correction form.

Complete the form from top to bottom.

  • Claims with an ICN displayed may have a remit posted or were previously corrected.
    Claims without an ICN displayed may not have been adjudicated yet or reached the payer.

  • After completing the form, click the Resolve button to send the claim correction to the Submit queue, but stay on the current page to continue resolving corrections.
    Click the Resolve and go to Submit Claims only when resolving the last correction you intend to work on and navigate away from the corrections list.

 

Weekly Task: Pushing New Treatments Toward Claim Creation

Submitting treatments to billing from the Attendance calendar on a weekly basis ensures a regular cadence for new claims billing and allows your organization to reliably schedule claims for follow-up and project incoming revenue.

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Step

Action

Tips and Notes

Review all marked treatments

Go to Attendance > Unsubmitted Attendance

Review the dates of service and services marked for each patient displayed

  • Run a new report in the EHR/EMR to compare against marked services and review to see if any changes were made to treatment notes.

Push marked services to claim creation queue

Use the Select None/Select All buttons, the Toggle link below the patient’s name, or checkmark boxes above each service to select services.

Click the Submit Treatments for Billing button

  • Submitting treatments to billing from this tab allows you to view and submit for more than one week at a time in one table.

 
 

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