Build athenahealth custom claim rules for the regional commercial payers that deny your claims most often. The standard scrubber is tuned to the network average. Your local payers do not bill to the average. Rules written to their specific policies stop preventable denials before the claim leaves the building, and that protects margin you have already earned. Three inputs, none of them exotic: denial data, payer policy, an owner. The rule builder itself gets covered below, along with what a workable edit looks like, who keeps the rules current, and what the effort buys in cash flow.
Key Takeaways
- The default athenahealth claim scrubber setup covers national and common payer rules. It does not cover every regional plan’s quirks.
- Custom claim edits athenahealth supports hold a claim for a payer-specific problem before it goes out.
- Pre-submission claim edits athenahealth runs work only when someone owns them and updates them as payer policies change.
- Clean claim rate optimization athenahealth practices measure comes down to first-pass payment on the claims their top payers deny most.
- A small starter set of rules for the top local payers usually covers most of the avoidable denials.
Last updated: October 23, 2026
Why the Standard Scrubber Misses Regional Payer Rules
athenahealth builds its scrubber to serve the whole network, so the rules inside it lean national. National coding edits, common payer requirements, patterns drawn from thousands of practices. For most claims that is enough. The trouble starts with the exceptions, because the rule set can only reflect what most payers want most of the time. Regional plans are the exception, and they do not all misbehave the same way. A modifier here that nobody else in the market touches. A prior auth number expected in a field most payers leave blank. Two codes bundled into one where the national edits bill them apart. Behavioral health or imaging shipped off to a delegated entity with submission rules of its own. None of it wild, just local.
None of these are errors in the scrubber. They are local requirements the scrubber was never built to know. The claim goes out clean by network standards and comes back denied by the payer’s standards. Money goes out twice on each denial. Once when payment arrives late. Once when staff hours go into correcting, resubmitting, appealing. At a few dollars of rework per claim, a year of volume turns that into real money.
The scrubber defaults mirror what the average payer wants. One regional plan with one odd policy can keep sending denials all year, and no built-in edit will catch them.
How the athenahealth Billing Rule Builder Works
Claim Custom Rules is the name inside athenaNet. The idea is plain. Before a claim goes out, it passes through whatever checks the practice has added, and each rule watches specific claim fields for a problem it knows about. A rule has three working parts. Scope comes first, usually one payer or payer group, sometimes narrowed by provider, department, or place of service. Then the condition that trips it: a procedure code paired with the wrong diagnosis, a modifier missing, an authorization field blank. The action comes last, and for most edits that is a hold in a work queue with a short note for staff on what to fix.
Do not underestimate the message on the hold. Vague wording sends staff hunting. A precise one-line note ends the hunt before it starts. After that, the rule simply runs on every claim within its scope. Nobody has to remember it exists. The payer quirks that used to live in someone’s head, or on a sticky note, live in the system instead.
Out-of-the-Box Rules Compared With Custom Claim Rules
| Factor | Out-of-the-box rules | Custom claim rules |
|---|---|---|
| What they catch | National coding edits, common payer requirements, network-wide patterns | Payer-specific modifiers, authorization fields, local bundling, carve-outs |
| Who maintains them | The platform | The practice or its billing partner |
| Typical impact | Broad baseline of clean claims | Fewer repeat denials from the practice’s own top payers |
What a Good Custom Claim Edit Looks Like
Denial data, not instinct, should decide which rules get built. Pull the reports by payer and reason code, then look for the same reason showing up on the same kind of claim over and over. That repetition is the signal. A rule aimed at it will pay for itself. A good rule is narrow. It targets one payer, or one payer group, and one problem. Broad rules hold too many claims and train staff to clear holds without reading them.
Sources matter here too. Write the payer policy, bulletin, or contract section behind the rule into its documentation. Payer policies shift without notice, and a future owner needs a way back to the source before touching anything. A good rule tells staff what to do. The hold message names the issue and the correction. Staff should not have to research every hold.
A good rule is tested before it goes live. Run it against recent claims and confirm it flags the right ones and leaves the rest alone. None of this has to be built in house. Some practices hand the whole job to a billing partner instead. Our team provides athenahealth billing services covering denial analysis, custom rule building, and the ongoing upkeep those rules need as local payer policies shift.
A Starter Set of Custom Rules for Local Payers
| Rule focus | What it catches | What it protects |
|---|---|---|
| Payer-specific modifiers | Missing or wrong modifiers a local plan requires | First-pass payment on procedures |
| Prior authorization fields | Empty or mismatched authorization numbers | Payment on high-dollar services |
| Local bundling | Code pairs a regional payer bundles | Accurate billing and fewer recoupments |
| Carve-out routing | Services billed to the plan instead of its delegated entity | Timely filing on carved-out services |
| Diagnosis pairing | Diagnoses a payer will not accept for a service | Medical necessity approvals |
| Rendering provider enrollment | Claims for providers not yet active with a payer | Credentialed payment and fewer write-offs |
The Pre-Submission Claim Edits Workflow
The workflow around pre-submission claim edits athenahealth runs best on a rhythm. Payer policy starts it, testing proves it out, and someone keeps watching after go-live.
The Custom Claim Rule Lifecycle
From payer policy change to a rule that is updated or retired, then the cycle repeats.
- Payer bulletin or denial trend
- Rule documented with source
- Built in Claim Custom Rules
- Tested on recent claims
- Enabled
- Holds cleared by staff
- Monthly tracking
- Rule updated or retired
- ReviewReview comes first. Each month, billing staff read the payer bulletins and log the denials. Certain edits trace straight back to the national correct coding edits many commercial payers have adopted. The rest come from one plan’s own policy update.
- BuildThe second step is the build. The rule is written, documented, and tested. Then it goes live.
- MonitorThe third step is monitoring. Track how often each rule fires and how often the held claims needed a change. A rule that fires often with no real fix is too broad. A rule that never fires may be obsolete.
Who Maintains the Rules
Skip this part and the rules rot. Payers rewrite policies, refresh fee schedules, and shift services to new delegated entities, and a rule written two years ago either starts holding claims that were fine or quietly misses the new problems. One person or team should own the rule set. That owner keeps a log of every rule, its source, and its last review date. The owner reviews the full set at least once a quarter and after any major payer update. Coding questions can be checked against the coding edit FAQ library before a rule is changed.
Business Results From Clean Claim Rate Optimization
The first result is a higher clean claim rate. More claims are paid on first submission. Fewer claims come back for correction. Speed of payment is the second gain. Clean claims move on the payer’s normal cycle. Denied claims sit in rework, sometimes resubmission, sometimes appeal. Every day shaved off that path comes back as fewer days in A/R and steadier cash.
Workload is the third. With fewer denials to fight, staff spend less time on payer calls and appeals and more on front-end accuracy, patient balances, and the older claims still open. Margin is the last one, and maybe the quietest. Timely filing runs out on preventable denials and they turn into write-offs. Rules that catch the claim before submission keep that revenue in the practice. These gains extend to government plans. Practices with Medicaid volume should align rules with the state program coding edits as well as local commercial policy.
Conclusion
The standard scrubber is a sound foundation. It is not the whole job. Regional payers have rules the network average does not reflect, and those rules drive steady, preventable denials. Custom claim rules close that gap. Start with denial data. Build narrow rules with clear messages. Test them, assign an owner, and review them on a schedule. The return is a higher clean claim rate, faster payment, and less rework for staff. Practices that want support across the full revenue cycle can explore our medical billing and RCM services.
FAQs
They are practice-defined edits that run on claims before submission. Each rule checks specific claim fields for a defined scope, such as a payer. When conditions are met, the rule holds the claim with a message for staff to correct it.
Start small. Five to ten rules aimed at the top denial reasons from the top local payers usually cover most avoidable denials. Add more only when denial data supports them.
No. Custom rules sit on top of the standard scrubber. The built-in rules cover national and common payer requirements, and custom rules add the local layer.
Review the full set at least once a quarter. Also review after any major payer policy update or contract change. Retire rules that no longer fire or no longer match payer policy.
Most practices see fewer repeat denials from their main local payers. That leads to a higher clean claim rate, faster payment, and less staff time spent on rework. Results depend on payer mix and how well the rules are maintained.
