Athenahealth Features That Will Make Your Life Easier: Part 2- Claim Custom Rules

Anytime you see the words “My” and “Custom” in the same header, you just know it’s going to be good.

In this second installment of our “Athenahealth Features That Will Make Your Life Easier” series, we’re digging into My Custom Rule Parameters—a powerful but often underutilized tool that gives your Revenue Cycle team direct control over claim behavior before they go out the door.

What Are “My Custom Rule Parameters”?

Located in the Billing Admin section of athena, this feature contains six powerful tables that let you apply specific logic to how claims are handled. These are:

1. Procedures that Require Modifiers

2. Procedures that Require Coding Review

3. Non-Billable Procedures

4. Procedures that Require Authorization/Referral

5. Invalid Modifiers

6. Invalid Diagnosis Codes

Each table allows Revenue Cycle leaders to apply automated claim holds—either on HOLD or MGRHOLD status—based on criteria set by the practice.

Real-World Example: Coding Review Holds by Payer

Let’s say you’ve just discovered that a payer hasn’t been reimbursing you correctly for a specific procedure. Instead of manually instructing your billers to hold claims, or reviewing your Missing Slips list every day, you can do the following:

1. Use the “Procedures that Require Coding Review” table

2. Set up a rule to automatically place claims for that procedure—and that payer—on HOLD

3. Keep those claims paused while you work through resolution with the payer

This is a game-changer for RCM teams trying to reduce rework and get in front of denials before they happen.

Pro Tips

1. Rules can be added or adjusted quickly to react to payer trends or policy changes.

2. These tables support custom logic, allowing you to set holds by CPT code, modifier, or even specific diagnosis codes.

3. Start small: Add a few high-impact rules and monitor the outcomes before rolling out broader configurations.

Ready to Take Control of Your Claims?

Did you know this athena feature even existed?

If not—let’s chat! Our consultants can help you build smart, efficient rules that take the guesswork out of claim holds and help your team stay proactive.