The Avea Way: Best Practices for Configuration

  • Updated

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

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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.

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

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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

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

Default Issue Types

Located in Managing Org Admin > Configuration > Issue Types

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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

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Step

Action

Tips & Notes

Add Payer Rates

Practice Admin > Payers > Payer > Payer Rates

  1. Select Service
  2. Select Service Billing Profile
  3. Enter Amount
  4. Enter Contract Status
  5. Enter Effective Date.

 

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