Partners can use an existing Claims API call to bypass using the fee schedule or allowable schedule at the time of claim creation. This is useful in cases where a single procedure code is used for multiple service/products that have various price points, such as ophthalmology, or for practices with discount programs. Since the functionality effects claims where patient and/or insurer is a payer, please follow caution.
What is a Fee Schedule? What is an Allowable Schedule?
A Fee Schedules is a list of procedure codes and their corresponding fees charged by a practice under a contract with a particular insurance or allowable category. Fee schedules are created and managed in athenaNet by practice users.
An Allowable Schedule is a list of procedure codes and their corresponding reimbursement amounts that a practice expects to receive as payment from a particular payer. Allowable schedules are created and managed in athenaNet by practice users.
Traditionally when creating new claims via API, the following fields are automatically pulled in from practice/patient-insurance specific schedules based on the procedure code submitted:
- Unit Amount or Fees (from Fee Schedule)
- Allowable Amount (from Allowable Schedule)
- Allowable Min (from Allowable Schedule)
- Allowable Max (from Allowable Schedule)
- Allowable Schedule ID (based on patient’s insurance and practice configuration)
With these changes the Claims APIs allow partners to bypass allowable and fee schedules and pass in values for the fields listed above. Although the schedules are bypassed with this call, athenaNet will treat all claims in a similar fashion. The rules engine will scrub the claim and adds the claim to claims queue in a HOLD status. Practice staff members then will review each claim, resolve any issues, and set the claim to the proper status according to their claim workflow.
The following settings are required to be turned ON for this feature to work. In production, a practice will need to work with their Customer Success Manager, Project Manager, or call/create a ticket to the Client Support Center to activate the required settings. In Preview, partners should reach out to their athenahealth point of contact for assistance with these settings if necessary. These settings can be found through:
- Gear - Admin > Implementation > Settings (Under Practice Links > Client Functions)
- Turn ON the ‘Allow charge amounts to be populated via API’, for an ability to by-pass Fee Schedule
- Turn ON the ‘Allow charge allowables to be populated via API’, for an ability to by-pass Allowable Schedule
Once these settings are enabled, partners can use existing POST APIs to create claims that bypass athenaNet’s allowable and fee schedules if desired.
APIs and JSON object
Both of the following APIs can be used to create claims:
Claim Charges is a JSON object and an example is provided below:
"procedurecode" : "99213",
"units" : "1",
"unitamount" : "50",
"allowableamount" : "100",
"allowablemin" : "40",
"allowablemax" : "130",
"allowablescheduleid" : "6",
"linenote" : "testing is the best",
"icd10code1" : "Z0000"
Please note that all four ‘Allowable’ fields (allowableamount, allowablemin, allowablemax, allowablescheduleid) need to be passed in to bypass an allowable schedule. Allowable Schedule ID is the unique identifier to find the allowable schedule for the patient-insurance. A partner should contact the practice to obtain this information.
- Partners should be extremely cautious when using this functionality, since these calls effects claim process times in athenaNet, especially if an insurance company is the payer.
- Partners must check with the practice before passing in parameters that bypass allowable and fee schedules.