📵 Denials Worklist Page – Athelas

At a Glance

The Denials Worklist page is designed to point you directly at the most impactful denials to work, helping you maximize revenue collection for your practice.

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Best Practices

Check the Denials Worklist daily. New remittances come in all the time, along with new denials that require your team’s expertise.

When you’ve corrected a claim in your EHR, mark it as ‘Updated in EHR!’ This signals Athelas to grab the updated claim info and resubmit.

Click into individual claims to review the notes left by the Athelas Denials Team. Often these will tell you exactly what action is needed.

Periodically, someone on your team should review the ‘Not Workable’ category to either write these denials off, or take one last shot at correcting them.

🌐 Full Features Overview

The Denials Worklist page displays claims that require action. Any claim that has already been resolved (from resubmissions to write-offs) is excluded by default in order to provide a clear line of sight on the most impactful claims to work.

However, although your worked claims are hidden by default, they’re always just one click away in the Worklist Settings.

Header Tabs

The top of the Denials Worklist page displays three tabs:

Site Action Required

Denials in this category will be your top priority. Your practice is responsible for making necessary updates in your EHR and then marking claims as ‘Updated in EHR’ (see example walkthrough below for directions). Once the correct updates have been made, these claims will be resubmitted automatically within 24 hours.

Click here to skip ahead to an example walkthrough in which we’ll work denials for resubmission.

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You’ll also notice these filters on the Site Responsibility tab:

Not Started

These are denials on which no action has been taken.

Awaiting EHR Updates

These are claims where your staff has indicated that corrections have been made in the EHR. Once our importers have pulled in the corrections, these claims will automatically be resubmitted, and will disappear from the denials dashboard.

Blocked

Claims enter this status when a member of your team indicates that they need assistance from Athelas to resolve the claim. If you’re stuck and need help, mark the claim as Blocked.

Athelas Responsibility

Denials in this category will be worked and resubmitted by Athelas. No action is required on your part.

Not Workable

Denials are listed as ‘Not Workable’ if there are no available actions that will lead to approval (generally, things like duplicate claims and those that are too old to meet timely filing requirements end up here). Your practice should review and then write off these claims.

General Filters and Settings

The next items on the page are the General and Denial Detail filters, as well as the Worklist Settings. Use these to narrow your search and pinpoint the denials you want to view.

General

The Insurance Priority filter (in which you can specify Primary, Secondary, or Tertiary) is always active by default. You can add the following filters to your search as well:

Service Date Range

Latest Submission Date

Latest Date Posted

Facility

Provider

Patient

Billing Type

Denial Detail

By default, the Denial Type filter is active, and you can switch between Full or Partial Denial. You also have the option to filter your list by Reason, CARC, and/or RARC.

Toggling on the ‘Denials with Notes’ will display only denials for claims on which someone has written a note.

The ‘Your tagged Denials’ toggle will display only denials on which someone tagged your username in a note.

See this guide for more information on notes and tagging coworkers.

Worklist Settings

Using the Worklist Settings, you can add any resolved denial type back into the mix. Your options include:

Decision Pending

These claims have been resubmitted or are reprocessing. We’re awaiting an updated decision from the payer. We tuck these out of sight because no further action is required until either (a) we hear back from the payer, or (b) the payer takes long enough to respond that our Recon Team proactively seeks a decision from the payer.

Mark as Pending to put denials into this category.

Encounter Finalized

These denials have been resolved, leaving no outstanding balance. No further action will be taken on them. Finalized denials include claims determined to be non-workable, manual write-offs, failed appeals, encounters switched to self-pay, and other denial types that have reached their final state of resolution.

Mark as Finalized to put denials into this category.

Unposted Remittances

Although these claims are considered Denied, they have unposted remittances that are likely to change the claim outcome. Generally this happens when new remittances arrive without a reversal of the previous decision. These claims are managed by the Posting Team rather than the Denials team, as the unposted remittances may indicate that the claim is no longer denied.

Inconclusive Remittances

Although a payer has denied these claims, they’ve also indicated that we should ignore their response in favor of a different outcome, which is missing from our records. This happens in three circumstances: (1) OA-18: Denied as Duplicate - means we should defer to a previous decision. (2) B11: Transferred - means another payer is responsible for deciding the claim outcome. (3) A1: Service Denied - is a placeholder CARC sent in place of the true denial reason. When we receive one of these CARCs, we should have another decision on record. If that decision is not in our records, the claim becomes the responsibility of the Athelas Recon Team who is tasked with tracking down the true outcome. Once that outcome is found, the claim will automatically be routed to the Denials team if it’s still considered denied.

Missing Recon

We’ve received a remittance indicating nonpayment… but some portion of the remittance also appears to be missing. This most often occurs when one procedure receives a decision ahead of the rest of the claim, creating a fragmented remittance. To resolve this issue the Athelas Recon Team will hunt down the missing data, after which the claim will automatically be assigned to the correct team for resolution.

Overposted Encounters

These claims have been denied but also have conflicting remittances posted. Usually these conflicting remittances indicate that an approval has followed a previous denial, but without a reversal of the original decision. The remittances need to be untangled by our Posting Team before it’s clear if the claim needs to be worked as a denial.

Voided Denials

These denials have been invalidated by a Void request sent by Athelas or your staff. Some denied claims are later voided because they were never intended to be billed. Other times, payers will issue a denial as final confirmation of a void request. In either case, no further action is required.

Capitation Denials

The payer has indicated that portions of these claims were not paid due to a capitation agreement. Capitation payments will be paid to you separately rather than at the claim level. For that reason, these claims do not require action and are not included in your worklist by default.

Appeal Filed

A formal appeal has been filed with the payer, and we’re awaiting their final adjudication. Until the appeal is decided, this denial does not require further action.

Medical Records Sent

Supporting documentation has been delivered to the payer based on requirements detailed in the claim’s denial. This claim will be omitted from your worklist while we wait for the payer to process the supplied paperwork and reconsider their previous decision.

Reprocessing

The payer has been contacted directly and they’ve agreed to reprocess these claims. No further action is required until we receive an updated decision from the payer.

Each of these settings includes the corresponding explanation, listed above, describing exactly why this denial type is excluded from the Denials Worklist (and how Athelas is addressing them, if need be).

Denials by Month

This section allows you to see monthly denials data at a glance. It also acts as a monthly filter—simply click on a month so that the list below displays only that month’s denials, and click the month once more to revert.

Denial Reason Clusters

The dashboard is designed around a central organizing principle: solving one issue should resolve multiple claims.

We use two types of codes provided by the payer to identify denial causes:

Claim Adjustment Reason Codes (CARCS)

These describe the main cause of the Denial. Some of these are sufficiently vague that additional detail is needed, which is why we also get…

Remittance Advice Reason Codes (RARCS)

These optional codes provide a greater level of specificity that helps identify the root cause of the denial.

The dashboard groups your claims into CARC/RARC clusters, unifying all the claims with similar denial reasons so you can review them together.

Each group of claims contains a summary of the key details of the denial type.

Clusters are sorted by total charge amounts of the included claims so you can focus on the most valuable opportunities.

🔍 View the Notes for Clues!

While you’re viewing an individual claim, be sure to check any related notes left by either your coworkers or Athelas staff. These notes often describe the action required and/or the reason a member of your staff is needed to resubmit the claim.

See this guide for more information on Notes in Insights.

🔁 Example Walkthrough: Working Denials for Resubmission

Let’s look at this group of denials as an example case:

These eight claims were all denied due to the CARC CO-197, indicating that they were missing prior authorization upon submission.

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The solution:

Update their prior authorizations individually

Mark them as Updated in EHR in bulk

1. Update Prior Authorizations

The first move to make here would be to update prior auth in your EHR. That way, Athelas can pull that information directly within 24 hours, ensuring no discrepancies between Athelas and your EHR.

However, if you want to resubmit sooner than that, you can update prior auth manually in Insights as well.

There are two primary ways to update prior auth in Insights:

From the Patient Profile

Visit the patient’s profile and click into the ‘Prior Authorizations’ tab. From here, you can either update an existing entry or create a new one.

From the Encounter Details page

First, locate and open the target encounter.

You can add prior authorizations in the ‘Service Lines’ section in the encounter creation modal. Click Add Authorization(Fig. 1).

Click Create and fill in the required information. Be sure to click Save when you’re done (Fig. 2).

2. Mark as ‘Updated in EHR’

Once you’ve made the necessary updates, you can mark all claims in this group as Updated in EHR in bulk.

First, select all updated claims. Then, open the ‘Actions’ menu and select Updated in EHR.

All claims marked as updated in EHR will automatically move into the Athelas Responsibility tab for automatic resubmission within 24 hours.

Tracking Your Progress

As you work denials, you’ll most often take one of three actions:

Update in EHR

Because Athelas treats your EHR as the source of truth, all you need to do to trigger a denial resubmission is to update the claim in your EHR. We’ll automatically import the corrected data overnight to resubmit the claim.

This will be your most common way of working denials!

Once you’ve made a correction in your EHR, mark the denial as “Updated in EHR”

Mark as Blocked

If you’re stuck and cannot determine the solution for a Denial with Missing Info, you can mark that claim as Blocked to request Athelas’ assistance.

Write Off

Inevitably, some denials simply cannot be fixed. You’ll need to write these off.

Here is a list of all the actions you can take. Full definitions of all of the statuses listed in this Actions menu can be found in the description of Worklist Settings, earlier in this guide.

Bulk Resubmit

Bulk Push to Next Payer

Bulk Push to PR

Mark Not Started

Move to Not Workable

Updated in EHR

Mark as Blocked

This indicates that you are unable to work these claims and would like Athelas’ assistance.

Mark as Pending

Mark as Athelas Responsibility

Mark as Site Action Required

Mark as Needs Arbitration

These claims need decisions from payers before anything else can happen with them.

Mark as In Arbitration

Request Appeal

To mark denials as Updated in EHR or Blocked:

Select target claims. Then open the ‘Actions’ menu and select Updated in EHR or Blocked.

To write off denials:

Click into an individual claim and open the ‘Actions’ menu, then choose Write Off.

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Viewing Denials from the Claim Details page

Because many people also use the Claims Details page to analyze denials, there’s a filter to let you see any denials visible in the Denials Worklist:

This is slightly different from filtering to the Encounter Status of Denied, which includes denials that have been worked and omits partial and secondary denials.

There is an explanatory alert to help clarify the distinction between the two:

In Conclusion

Using the Denials Worklist page effectively will help you prioritize the most actionable denials, giving you the best shot at reclaiming lost revenue for your practice.

Related Guides

⛔️ Rejections Page

📨 How to Resubmit Claims in Bulk

🔂 How to Modify and Resubmit a Single Claim

📢 Further Assistance

We’re here to help! Please get in touch with support@getathelas.com if you’d like some hands-on assistance.