Athenahealth Claim Scrubbing and Denial Management Workflow: How to Clear Claim Holds

Athenahealth claim scrubbing is the automatic check athenaOne runs on every claim before it goes to the payer. The Rules Engine tests each claim against payer, coding and practice rules. A clean claim moves to DROP status and goes out in the next batch. A claim that fails a rule moves to HOLD or MGRHOLD with a claim note that explains the problem, and someone at the practice has to fix it.

This guide shows billing managers and practice owners how athenahealth claim scrubbing works in athenaCollector, how to clear claim rules, how to build custom rules, and how a daily denial management workflow keeps holds from piling up.

What Is Athenahealth Claim Scrubbing?

Athenahealth claim scrubbing is the job of the athenaOne Rules Engine. Each claim rule is a short piece of logic that looks at claim details such as diagnosis, procedure code, modifier, place of service, provider, payer and eligibility. When a rule finds a problem, it adds a note, changes the claim status, switches the claim format or splits the claim.

In practice, the scrub decides one thing: can this claim go out today? If every rule passes, the claim reaches DROP status. If a rule fires, the claim stops, and athenaOne adds a claim note with AUTO in the User column and SCRUB in the Action column that tells you what to fix.

Most rules come from athenahealth itself: global rules for payer requirements, predictive rules from denial trends, and local rules that athenahealth writes for one practice on request. On top of these, a practice can add its own custom rules.

How Athenahealth Claim Scrubbing Fits the AthenaCollector Workflow

AthenaCollector is the billing service inside athenaOne. To manage holds well, you first need to know where a claim sits and who owns it. The billing workflow runs in this order:

1. Charge entry. Staff enter charges from the billing slip, usually at the Checkout stage of the encounter, and athenaOne creates the claim.
2. Rules Engine scrub. Athenahealth claim scrubbing checks the claim right away and assigns a status.
3. Correction. Staff fix errors on the Claim Edit or Claim Action page, and the Rules Engine scrubs the claim again on save.
4. Submission. DROP claims go to the payer, and their status changes to BILLED.
5. Follow-up and posting. The remittance comes back, staff post it, and the claim either closes or moves to a work queue.

Claim Statuses at a Glance

The claim status tells you who has to act next. The table below sums up the statuses a practice sees most often.

How to Read an Athenahealth Claim Scrubbing Note

Every note the scrub adds belongs to one of three types, and each type needs a different response:

Rule notes appear in bold red. You must correct the error before the claim can reach DROP. No override exists.

Review notes are meant for billing managers. A user with the Claim Note Override: Review permission can override them after checking the claim. Custom practice rules use this type.

Advice notes flag a likely problem, such as a pattern that often leads to denial. A user with the Claim Note Override: Advice permission can override them. Predictive rules use this type.

Each note also shows a Business Requirement ID (BR-######). If a rule fired by mistake, give that ID to athenahealth support.

How to Clear Claim Rules in Athenahealth

Knowing how to clear claim rules in athenahealth comes down to a real fix and a clear trail. athenaOne will not resubmit a held claim until at least one thing on it changes, so always correct what caused the hold. Use these steps for a claim in HOLD:

1. Open the claim. Start from the Workflow Dashboard or the claim worklist, then open Claim Edit or Claim Action.
2. Read the claim notes. Scroll to the Claim Notes section, find the AUTO / SCRUB note, and note the kick code and BR ID.
3. Fix the cause. Correct the code, modifier, diagnosis pointer, authorization number, insurance package or demographic detail the note names. If the issue is unclear, call the payer first.
4. Set the status and kick reason. On Claim Edit, set Status to DROP and enter DRPBILLING as the kick reason. On Claim Action, choose Add Kick Reason and enter DRPBILLING.
5. Write a claim note. Say exactly what you changed and why, so the next person does not have to guess.
6. Save and confirm. athenaOne scrubs the claim again. If another rule fires, the claim moves to the worklist for that hold, and you repeat the steps.

Sometimes the right answer is not a resubmission. Use the PTRESP kick reason to move a balance to the patient, or Transfer Balance with Next Payer to send it to a secondary payer.

Common HOLD and MGRHOLD Kick Codes

Each held claim carries one kick code that points to the fix. In HOLD, common codes include AUTH, CPT, DIAGNOSIS, DXCPTMATCH, MODIFIER, IPN and PTADDRESS. In MGRHOLD, you will often see CLMDUP, CREDENTIAL and MEDPOLICY. athenahealth publishes a correction guide for every kick code.

Configuring Custom Rules for Athenahealth Claim Scrubbing

athenaOne does not have one screen called a Claim Rule Builder. Instead, users with the Billing Admin: Custom Rules permission build custom rules on category pages, one for each kind of rule. The six categories cover procedures that require modifiers, authorizations and referrals, coding review, invalid diagnosis codes, invalid modifiers, and non-billable procedures. Together they work as your practice-level claim rule builder.

Custom rules earn their keep when the same error keeps coming back. For example, if one payer always denies a procedure without a certain modifier, a custom rule can hold those claims before they leave. You can also pair the Procedure Code Filter with the Additional Procedure Code Filter to target two codes billed together.

Even so, too many rules slow a practice down, because every rule that fires creates a hold someone has to work. Follow these habits:

• Keep each rule as narrow as possible, and write instructions that tell staff exactly what to check.
• Give rule creation and monitoring to one trained person or a small team.
• Review every custom rule each quarter and retire the ones that no longer catch real errors.
• For a payer requirement that affects many practices, open a support case and ask athenahealth to scope a global rule instead.

The athenaOne claim rules guide lists the full options for each category, including overrides and the Fire Only Once setting for coding review rules.

Clearinghouse Hold: Rejections Before the Payer

A claim can pass your scrub and still bounce. When the clearinghouse or the payer rejects a claim at the front end, for formatting, routing or a payer ID problem, athenaOne usually places it in ATHENAHOLD. In other words, this is the clearinghouse hold. On the standard service, athenahealth researches and resubmits these claims, and kick codes such as PAYORID, ANSIBATCH, CST and EMCREJECT show what went wrong. Our list of clearinghouse rejection codes explains what the most common rejections mean and how to prevent them.

ATHENAHOLD also covers a payer whose ERA enrollment is almost complete. athenaOne holds those claims until enrollment finishes and then releases them, or sends them on paper if the filing deadline gets close. The ATHENAHOLD status guide lists each kick code and its expected turnaround.

ERA Payment Posting and Denials

ERA payment posting is where denials enter the workflow. When the remittance comes back, the Posting Team (or your own staff on No Posting) posts payments and adjustments. If the ERA or EOB shows a denial, the claim moves to CBOHOLD. On the standard service, athenahealth then corrects and resubmits it, contacts the payer, or sends it back to the practice with advice. Coding denials can return to MGRHOLD tagged CODING ADVICE, ADVICE TO ADJUST or DOCUMENTATION REQUEST. Since April 2025, athenaOne writes some of these notes automatically, with “athena auto” or “AI Insight” as the user.

In short, posting tells you what went wrong after the fact, and athenahealth claim scrubbing stops it beforehand. A strong athenahealth denial management workflow connects the two: every denial that repeats should become a scrub rule. Our guide to medical claim denials covers the denial codes that most often deserve a rule.

A Daily Athenahealth Denial Management Workflow

The athenahealth denial management workflow that works best is short, daily and owned by named people. Claim worklists help, because athenaOne assigns claims oldest first, one worklist at a time. Here is a routine that pairs well with athenahealth claim scrubbing:

1. Start with ATHENADROP. These claims are close to the filing deadline, so clear them before anything else.
2. Work HOLD claims. Fix front-desk and coding holds the same day, while the visit is still fresh.
3. Work MGRHOLD claims. A billing manager handles duplicates, credentialing issues, adjustments and refunds.
4. Check returned denials. Read the advice on claims athenahealth sent back, then correct, appeal or adjust.
5. Split current work from backlog. Use date filters to build separate worklists, so old claims do not crowd out today’s.
6. Turn patterns into rules. Once a week, find repeat errors and decide whether a custom rule or a front-desk fix would stop them.

Athenahealth Claim Scrubbing Example: Clearing an Authorization Hold

Consider a hypothetical orthopedic practice that bills an injection for a commercial patient. The claim lands in HOLD with the kick code AUTH, because the authorization number is missing. First, the biller finds an approved authorization in the payer portal that never got entered. Next, she adds the number, sets the status to DROP, enters DRPBILLING and writes a note: “Added auth on file with payer.” On save, the scrub passes and the claim goes out. Finally, because this is the third AUTH hold this month, the practice adds an authorization step to scheduling.

When to Bring in an Outside Team

athenaCollector does a lot of the work, but it does not work your HOLD and MGRHOLD queues. Practices often fall behind when a biller leaves, when they add providers, or when they move to a No Follow-Up or No Posting service level. If holds keep growing, an outsourced medical billing partner that already knows athenaOne can clear the backlog, set up useful custom rules and keep your first-pass rate high. To see what a clean first pass looks like, read our guide to clean claims and clean claim rate.

Frequently Asked Questions