This article aims to guide you through the main features we are adding and changing in Claim Resolution with the transition from a line item-based workflow to a claim-based workflow.
Workflow statuses and payment issues
How workflow statuses and payment issues interact
Setting up payment issues and workflow statuses
Payment Issues in Claims Analytics
1. Workflow statuses and payment issues
Workflow statuses at the claim level are the primary “workflow” capability in Rivet. When a user takes an action on (i.e. “Appeal 1”) a denial or wants to categorize (i.e. “Payer will reprocess”) a denial, they should change the workflow status of that claim.
There are, however, a few limited circumstances in which a workflow status at the claim level is not enough. Depending on your SOPs, you may consider some line items “Closed” or not worth working right off the bat. For example:
Procedure codes that you always write off
Denials from secondary payers stating that the primary payer is responsible
Denial reasons you’ve determined aren’t worth appealing, whether in general or for specific payers
Claims that have more units than a payer allows
Other circumstances where a denied line item should not be worked
To address these limited circumstances, Rivet will now offer the ability to create payment issues at the line item level. By default, Rivet comes with the payment issues Denied and Closed. Users can create custom payment issues, which are useful for ensuring teams do not address specific line items in claims and for more granular reporting. Payment issues can only be applied to line items via automation rules created in the settings page. When we receive an electronic remit (e.g. 835) for a line item, the Paid payment issue will override any other payment issue, including custom ones.
2. How workflow statuses and payment issues interact
Generally, workflow statuses and payment issues should be considered separate concepts. The only exceptions are the claim level workflow statuses of Detected and Closed.
5. Setting up payment issues and workflow statuses
Determine which line items you do not want your team to work, such as:
Procedure codes that you always write off
Denials from secondary payers stating that the primary payer is responsible
Denial reasons you’ve determined aren’t worth appealing, whether in general or for specific payers
Claims that have more units than a payer allows
Other circumstances where a denied line item should not be worked
Create your custom payment issues
Set up automations for those line items based on the criteria you determined in step 1
Create your custom workflow statuses
6. Payment issues in Claims Analytics
Payment issue totals are shown in the payment issue table. Line items with custom payment issues are counted towards Denied Line Items in the columns for subsequent tables. Clicking on a row in Claims Analytics will take you to the same claims list it did before.
Worklist
The claim level worklist is practically identical to the line item level worklist, except that each row is now a complete claim rather than a line item on a claim.
Filters and grouping on the worklist work on a “contains” principle. This means that filtering for a specific criteria will give you a list of claims that contain line items that match those criteria. Grouping works on the same principle. The only exception here is that the status filter refers to the claim’s workflow status, not the payment issues of line items in the claim. The saved views you created previously will migrate over to the new worklist.
Detail view
The detail view for a claim is designed to show you all the information contained in a claim in a way that lets you see the entire picture as well as the specifics of each line item.
The graphic above provides an overview of the detail view of a claim that is accessed by clicking on a row in the worklist. Claim information is displayed on the left. Notes and status changes apply to the entire claim, and the transaction details formerly visible by clicking on a “View claim” button are now visible in the “Transaction history” tab.
To see line-item-specific information, such as adjustment code and remark code, click on any of the line items in the table. This will open a right-hand panel with information regarding that line item, as well as instructions for successfully resolving that line item.
When a claim is ready to be appealed, click on the “Appeal assistance” button on the top right. This will open up a new module with tools to help speed up appeals.
The lefthand column is designed to make payer portals easier and less tedious. If you want to save 5 minutes every time you use a payer portal and have not installed the Payer Portal Automator yet, please follow this link. It’s easy to set up, free, and our support team will be happy to walk you through it at any time.
The center column is designed to make appeal forms easier and less tedious. Rivet can automatically fill out these forms for you in one click. If you do not see an appeal form available here, it’s as easy as uploading a PDF. For help getting appeal forms to auto-fill, please follow this link.
The right-hand column contains payer contacts if you want to reach a payer manually.
Rivet’s Claim Resolution product is transitioning from a line item-based paradigm to a claim based paradigm because of your feedback. While we try at all costs to avoid making product changes that affect customer workflow, we’ve heard feedback asking for a claim level view for a long time, and we genuinely believe that this transition will make Rivet better.
Why we are changing to a claim-level paradigm
When will this transition happen
What functionality will be transitioned
How existing line item statuses will transition
1. Why we are changing to a claim level paradigm
A claim level paradigm will make Rivet better because it more closely matches how denials work outside of Rivet. Some examples:
When you appeal a denial, you appeal the whole claim at the same time
When you call a payer about a denial, they’re looking at the whole claim at the same time
EHR/PM systems work at the claim level
Besides more closely matching how denials work outside of Rivet, we anticipate a claim level paradigm will improve the workflow and efficiency of denials teams because:
Claims often have one line item denial that is the “keystone” for getting the entire claim recovered. The claim level detail view is designed to give users a high-level view of the claim so they can identify the “keystone” line item, resolve it, and recover the entire claim with less effort.
One person generally works an entire claim at once, as opposed to different people on different line items. Claim level assignments support this.
We understand that this is a disruptive change, and we are putting all our efforts into making it as smooth as possible. Please schedule time with your Customer Success Manager if you have any concerns.
2. When will this transition happen
You have two weeks before we transition your account from being line item based to being claim based. This transition will occur on 10/24/23. Once you transition to a claim level workflow, you cannot transition back to a line item workflow.
You will receive an invitation to do training on this new paradigm.
If you have concerns about this transition, please schedule time with your customer success manager as soon as possible.
3. What functionality will be transitioned
Functionality that is not transitioning automatically:
Create custom payment issues
Functionality that is transitioned automatically
Line item statuses → workflow statuses (as explained below)
Saved views
Assignments (both existing assignments for active denials and assignment rules)
Exclusions
Automations
Please note that Automations will no longer directly affect workflow statuses at the claim level. They will only affect payment issues at the line item level.
💡 Customers transitioning to a claim-level workflow will need to set up custom payment issues.
4. How existing line item statuses will transition to the claim-level workflow
We will be using the following logic to transition customers’ statuses from Rivet’s old line item workflow to our new claim level workflow.
If no user actions have been taken on any line item in a claim:
If all the line items in a claim previously had a status of X, then the claim workflow status will be X.
And if there’s a mix of statuses among the line items on the claim, then the claim workflow status will be In Progress.
If there are user actions on any line item in a claim, then the most recently updated line item status becomes the status of the entire claim.
If you have further questions about the transition to claim-level workflow please schedule time with your customer success manager as soon as possible. or send an email to success@rivethealth.com.
Suggested Next Article: Understanding the Claim Level Workflow (Denials)