Optimizing claim management

Enhancing claim visibility and automation at scale with Advanced Claim Status

For most healthcare organizations, claim management often spans multiple sites, teams, and systems. Manual status checks create bottlenecks — consuming staff time, slowing reimbursements, and straining financial performance. Without automation and reliable data, administrators face the dual challenge of managing high claim volumes while maintaining oversight.

athenahealth’s Advanced Claim Status reduces the administrative burden by automating updates, delivering richer data, and fitting into existing workflows. Built through collaboration between athenahealth’s Group Management and Electronic Data Interchange (EDI) teams, the solution helps large organizations standardize processes, reduce fragmentation, and improve efficiency at scale.

The challenge: manual and fragmented claim management processes across large organizations

Many claim status transactions still rely on the X12 276/277 standard, a common electronic format for checking in on claims with payers. This standard often leaves billing teams with incomplete or delayed information.

At scale, those gaps multiply — requiring administrators to manage multiple portals, phone calls, and manual updates across thousands of claims. The result is a fragmented process that can cause missed updates, delayed payments, and unnecessary stress for staff.

Such challenges make the need for a more automated, reliable, and detailed claim status solution even greater. Providers need real-time, normalized visibility into every stage of a claim — from payment details to denials, adjustments, and other critical updates — delivered within the enterprise systems their teams already rely on.

What Advanced Claim Status means for enterprise operations

Advanced Claim Status addresses the most frustrating parts of claims management by combining modern API technology with seamless workflow integration. Its key capabilities include:

1. Automated data pull: It starts by automatically gathering a list of invoices that need status checks from aging queues in the Group Management environment.
    
2. Real-time status retrieval: The athenahealth EDI team processes that list and uses payer APIs, currently tapping into Availity — a leading healthcare clearinghouse that connects providers to 450+ payers — to pull the latest claim updates.
    
3. Clean, consistent information: No matter which payer the data comes from, it’s normalized for consistency and enriched with extra details when available.
    
4. Instant workflow updates: Those claim statuses and notes flow right back into Group Management, updating tasks automatically — no extra clicks, no manual entry.

This end-to-end automation allows revenue cycle teams to spend less time chasing claim updates and more time on strategic, high-value work, such as denial prevention and financial performance improvement.

Unlocking richer claim insights with enhanced responses

One of the standout features of the Advanced Claim Status solution is its ability to work with two types of API responses from payers:
 

• Standard response: Includes the essentials — payment status, check number and date, denial or rejection codes, and remark codes — so teams can quickly see whether a claim has been paid, denied, or is still pending.
   
• Enhanced response: Adds a deeper layer of detail, such as allowed amounts, adjustment reasons, deductible and coinsurance amounts, and even primary payer payments for secondary claims. With this richer data, administrators can identify trends, diagnose issues faster, and make more informed decisions about resource allocation and payer strategy.

Today, about 85 payers support the enhanced response, including major commercial carriers and many Blue Cross Blue Shield plans. Coverage continues to expand, enabling large organizations to access richer, more standardized claim data across their payer mix. This growing coverage transforms how large organizations manage revenue cycles with greater speed, accuracy, and control.

Transforming enterprise revenue cycle management

The Advanced Claim Status solution delivers practical benefits that make revenue cycle management faster, more consistent, and easier to scale: 

1. Less manual work
   The entire claim status check process runs automatically — reducing thousands of hours of manual effort and allowing leaders to redeploy staff to higher-value tasks.
    
2. Consistent information
   Data from different payers is normalized into a single format, so teams can interpret claim status quickly and confidently.
    
3. Deeper claim insight
   Enhanced response data provides service line-level details, adjustment reasons, and financial breakdowns, enabling better denial management and forecasting.
    
4. Broad payer coverage
   The solution connects to 450+ payers through Availity’s API network, with more integrations on the way — most requiring no additional enrollment.
    
5. Seamless workflow integration
   Claim status updates appear in familiar Group Management task queues, so teams can review and act without adopting new systems.

Today, about 85 payers support the enhanced response, including major commercial carriers and many Blue Cross Blue Shield plans.

Architecture and workflow built for scale

The Advanced Claim Status solution is built on a technical foundation that’s both powerful and easy to maintain: 

• Configurable queue extraction: Teams can choose exactly which aging queues to monitor, so claim checks focus on the invoices that matter most to their operations.
   
• Single integration point: By tapping into Availity’s API network — a secure way for different systems to share data — the solution connects to hundreds of payers without the headache of managing separate integrations.
   
• Automated file transfers: Invoice lists and claim status results move automatically between Group Management and athenahealth EDI, eliminating the need for manual uploads or downloads.
   
• Task updates with actionable notes: Updated claim statuses appear directly in task queues, complete with clear notes explaining denials, adjustment reasons, or resubmission requests, so staff always know the next step.

This architecture is designed to support growth across large, complex organizations, remain reliable in daily use, and minimize the IT resources required for ongoing maintenance.

Empowering organizations with advanced claim status

The Advanced Claim Status solution marks a major leap forward in claim management. Automating status checks, improving data quality, and fitting seamlessly into existing workflows help healthcare organizations cut down on administrative work, speed up reimbursements, and strengthen their financial health.

As healthcare technology advances, this solution reflects athenahealth’s commitment to building tools that combine innovation, collaboration, and empathy —helping large healthcare organizations in scaling efficiently while delivering exceptional care to patients.

Stay tuned for upcoming beta opportunities and new enhancements that will continue to shape the future of claim management.