👾 Encounter Stage and Status

Import errors can occur for several reasons, including unrecognized or missing insurance, missing procedures or ICD-10, etc.

The patient is self-pay, so the full balance is PR.

The encounter will be submitted in its corresponding batch.

There was a problem with submission. Athelas is working on it.

The claim was successfully submitted and awaits either approval or denial.

The current payer has paid, or the next payer balance is > 0. In other words, if any payer has paid any amount.

Claims can be rejected by a clearinghouse for a number of reasons before they are sent to insurance companies for either approval or denial.

In rare cases, an error will slip past a clearinghouse and be rejected directly by the payer.

See this guide for more information on Rejections.

Claims can also be denied by a payer for numerous reasons.

See this guide for more information on Denials.

Athelas voids claims when they contain so many errors that it would be easier to create and submit an entirely new claim, rather than revising the current one.

These are claims that Athelas imported from the time prior to our partnership with your practice (before the ‘Go Live date’).

The current payer responsible for adjudicating the remaining balance on the claim.

The balance is now PR.

If there are any pending/manual review remittances, the encounter will enter the ‘Finalization Pending’ stage instead of the ‘Finalized’ stage. Posting the remits or archiving them will lead to finalization.

No further actions will be taken on this encounter.

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 with a remittance, or (b) the payer takes long enough to respond that our Recon Team proactively seeks a decision from the payer.

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 remittance(s) may indicate that the claim is no longer denied.

We’ve received a remittance indicating nonpayment, but some portion of the remittance also appears to be missing. This most often occurs when a payer makes a decision for a one procedure before 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. The claim will still appear as ‘Missing Recon’ until the Recon Team completes their task.

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.

Claims that get to this sub-stage include only informational CPT codes (they end in ‘F’) , and at least one procedure is listed with an allowed amount of $0. We don’t expect payment for these claims, no action required, then we mark them as approved and finalized.

At least one procedure in the claim has an allowed amount of $0, and another has an allowed amount greater than $0.

Each procedure has been approved with at least some payment towards all, but at least one is not yet balanced because the payer has not yet paid in full. These are distinct from ‘Partially Paid’ claims, in which the patient has not yet paid in full.

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.

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.

The patient has not yet paid the PR on these claims. Ask the patient to pay

Claims with this sub-stage have a payment associated with them, but a balance remains because the patient has not paid in full (as opposed to missing payer payment, indicated by the ‘Unresolved Balance’ sub-stage).

Although the payer has denied these claims, they’ve also indicated that their denial should be disregarded in favor of another outcome—one that is currently missing from our records. This typically occurs in three cases:

When one of these CARCs is received, we should already have a corresponding decision on file. If no such record exists, the claim is escalated to the Athelas Recon Team, which is responsible for identifying the correct outcome. Once the true outcome is located, the claim will be automatically routed to the Denials team—if it is still considered denied.

In rare circumstances, Athelas will force finalize erroneous edge cases that should not count as Denials, such as bad imports or pre-launch encounters that were already finalized, for example.