Best Practices for Configuration

Objective

This page should serve as a guide for Billing Managers & Team Leads on how to best set up your AveaOffice configuration for your organization’s unique needs. Through the process of workflow customization, along with best practices for how to champion these within your team, your organization will reap the benefits of a well-organized RCM workflow.

Responsible

Billing Managers & Team Leads will be responsible to create and manage the list of queues, statuses, and issues (QSIs) based on the needs of their team.

Billing Managers & Team Leads will also be responsible to make sure Billing Collection and Payment Posting team members adhere to the QSI process created.

QSI Customization

Step	Action	Tips & Notes
Adding Queues	Managing Org Admin > Configuration > Claim Queue Types > Create Claim Queue Type. Create one queue per area of the claim lifecycle.	Create queues based on the teams at your organization. If you are a highly staffed outlet, you may have a specific Appeals department that could have their own queue. See The Avea Way - Best Practices for Updating Claim Workflow for what each default queue means.
Adding Statuses	Managing Org Admin > Configuration > Claim Status Types > Create Claim Status Type.	Create simple and specific statuses for your claims based on where it is in the lifecycle. That way, there is no confusion when it comes to which status is the best one to use. Simple and specific statuses will also ensure your team can notate correctly on the claim.
Adding Issues Sources	Managing Org Admin > Configuration > Claim Issue Sources > Create Claim Issue Source.	Create issue sources based on the different departments in your organization where issues can arise. Issue sources should be simple to ensure you can easily match them to the different issue types that you have created.
Adding Issue Types	Managing Org Admin > Configuration > Claim Issue Types > Create Claim Issue Type.	Create issues types based on the different billing scenarios that are delaying reimbursement on a claim. Remember, issue types should be simple and specific so that all team members can quickly determine the most accurate combinations for their notes.   See appendix below for how the different issue sources relate to the different issue types.
Settings	Managing Org Admin > Configuration > Settings.	See appendix below for an explanation of the default settings in AveaOffice.

 

Queues, Statuses, and Issues provide a unique workflow that billers can easily adopt in order to keep claim follow-up organized, and provide their organization with insight into key issues.

The Avea Onboarding Team will pre-fill client accounts with Queues, Statuses, and common Issue Types but clients should take time to review the lists to determine if any are missing from their organization's standard workflow.

Default Settings

Located in Managing Org Admin > Configuration > Settings

Setting	Recommendation	Tips & Notes
Default Claim Queue for First Claim Instance	Payer Queue	Assign this to the queue where Billing Collections will look to find claims to follow up on for the first time.
Default Claim Queue Upon Claim Resubmit	Payer Queue	Assign this to the queue where Billing Collections will look to find claims to follow up on after a claim was resubmitted.
Default Claim Queue Upon EOB Receipt	Review Queue	Assign this to the queue where Payment Posters will look to find claims to follow up on after payment was received.
Default Claim Queue Upon Claim Rejection	Resubmit Claim Queue	Assign this to the queue where Billers will look to find claims to correct after they have been rejected.
Default Claim Queue Upon Payer Hold	Payer Queue	Assign this to the queue where Billing Collections will look to find claims to follow up on after a claim was marked as held.
Default Claim Queue Upon Unbalanced Payment	Unbalanced Payment Queue	This queue is automatically created and works in tandem with the Out of Balance Work Center for Payment Poster to review.
Default Claim Queue Upon Balance Ignore	Balanced Ignored Queue	This queue is automatically created and works in tandem with the Out of Balance Work Center for Payment Poster to review.
Default Claim Status for First Claim Instance	Payer - Original Claim Processing	Select a status that tells Billing Collections that this is the first time this claim is being followed-up on so they will know initial claim status is needed.
Default Claim Status Upon Claim Resubmit	Payer - Resubmitted	Select a status that tells Billing Collections that this is the first time this claim is being followed-up on after resubmitted so they will know to review the claim notes and make sure the payer processed the correction accurately.
Days to Follow-Up on Claim Submit for First Instance	30 Days	Set a follow-up date default that will allow the payer enough time to process your claim before you follow up for the first time. We recommend between 20-30 days.
Days to Follow-Up Upon Claim Resubmit	15 Days	Set a follow-up date default that will allow the payer enough time to process your resubmitted claim before you follow-up.
Maximum Charge for New Multi-Day Claim ($)	$10,000	Set the maximum charge amount that a claim can be created in AveaOffice with.
ICD-10 Requirement Effective Date	10/1/2015	Always set this for 10/1/2015 when ICD-10 became required.

 

Default Issue Sources

Located in Managing Org Admin > Configuration > Issue Sources

• Billing
• Payer
• Provider
• UR
• VOB
• Write-Off

Default Issue Types

Located in Managing Org Admin > Configuration > Issue Types

Source	Type
Billing	Demographics Error - Data Entry Address
Billing	Demographics Error - Data Entry Client Name
Billing	Demographics Error - Data Entry Dob
Billing	Demographics Error - Data Entry Gender
Billing	Duplicate Claim
Billing	Incorrect Coding Used - Admit Discharge Date
Billing	Incorrect Coding Used - Bill Type
Billing	Incorrect Coding Used - Cpt/Hcpc Code Used
Billing	Incorrect Coding Used - Rev Code
Billing	Incorrect Diagnosis - Diagnosis Used Invalid
Billing	Incorrect Member ID - Data Entry Error
Billing	Incorrect Payer - Submitted To Medical vs Behavioral
Billing	Incorrect Payer - Submitted To Wrong Payer
Billing	Incorrect Provider - Incorrect Facility
Billing	Original Reference Number Invalid
Billing	Submitted In Error - After Client Discharged
Billing	Submitted In Error - Before Client Admitted
Billing	Submitted In Error - Not On Census
Payer	Claim Not On File - Electronic
Payer	Claim Not On File - Paper
Payer	Delayed Processing - Paper Claim Processing
Payer	Delayed Processing - Payer Did Not Specify Reason
Payer	Delayed Processing - Payer System Issue
Payer	Medical Records Requested
Payer	Medical Records Under Review
Payer	Paper Claims Not Accepted For Minnesota Address
Payer	Payer Keying Error
Provider	Enrollment Not Completed Prior To Billing
Provider	Provider Address Incorrect At Payer
Provider	Provider Not Registered With Payer
Provider	Tax ID Not On File With Payer
UR	Auth Keying Error
UR	Auth Not On File With Payer
UR	Authorization Incorrect At Payer
VOB	COB Not Completed
VOB	Coverage Terminated
VOB	Maximum Benefits Reached
VOB	No OON Coverage
VOB	Non-Covered Service
VOB	Timely Filing
Write-Off	All Appeals Exhausted
Write-Off	Coverage Terminated
Write-Off	Max Benefits Reached
Write-Off	No OON Coverage
Write-Off	Non-Covered Service
Write-Off	Timely Filing

Payer Rates

Located in Practice Admin > Payers > Payer Rates

Step	Action	Tips & Notes
Add Payer Rates	Practice Admin > Payers > Payer > Payer Rates Select Service Select Service Billing Profile Enter Amount Enter Contract Status Enter Effective Date.	Create payer rates based on your contracted and non-contracted rates with certain payers. As you collect more data, you will be able to start identifying trends around OON reimbursements to add OON expected rates. The AveaOffice reports that will show payer rates are: AR Report AR Waterfall Report Claim Status Reports Claim Submission Report Combined AR Detail Report Insurance Adjustments Report