Carving Out Claims Based on Alternate Payer Configuration

File Maintenance Help for NextGen® Enterprise

Create an Alternate Payer Carve-Out Criteria

In File maintenance, select Master Files > System > PM and then select Payers. The Payers List window opens. Double-click a payer. The Modify Payer Information window opens. Select the Alt Payer tab. To create an alternate payer carve-out criteria, select open menu and then select New. The Add Alt Payer Carve Out Criteria window opens. In the Alt Payer Criteria section, do the following: Select an alternate payer from the list. You can also create a new alternate payer by selecting the open menu in the Alt Payer Criteria section and then following the steps mentioned in Add an Alternate Payer. Select the effective and expiration date. Enter the description for the alternate payer carve-out criteria. Note: The alternate payer carve-out criteria details are practice specific. Select the required location. Note: When you select a location, the fields in the Billing Provider Information section are enabled. To enter the SIM range, select open menu and then select New. The Alt Payer Number

File Maintenance Help for NextGen® Enterprise

Modify Alternate Payer Carve-Out Criteria

In an alternate payer configuration, you can configure the same alternate payer multiple time with unique effective dates. Once you save the alternate payer configuration, you will not be able to change the alternate payer. Note: You cannot delete an alternate payer configuration. In File maintenance, select Master Files > System > PM and then select Payers. The Payers List window opens. Double-click a payer. The Modify Payer Information window opens. Select the Alt Payer tab. From the Alt Payer Configuration list, select an alternate payer and do one of the following: Select open menu and then select Open. Right-click an alternate payer and then click Open. Double-click an alternate payer. The Modify Alt Payer Carve Out Criteria window opens. Modify the alternate payer carve-out criteria as required. For more information, refer to Create an Alternate Payer Carve-Out Criteria. To save the changes and close the window, select OK. Parent topic: Configuring Alternate Payers

Help Guide for NextGen® Enterprise PM 8

Carving Out Claims Based on Alternate Payer Configuration

The FQHC practices typically set up a payer in File Maintenance for UB claim (Medicare Part A) and associate an alternate payer to the payer (Medicare Part B) that carves out the SIM codes to a 1500 claim. This setup allows you to attach an insurance to the encounters of medicare patients that automatically splits the services to separate claims based on the SIM codes. You can carve-out charges into multiple electronic or paper claims based on the payer master setup. You can generate alternate payer claims based on the alternate payer billing options setup in the Payers-Alt Payers master file. You can either create a professional claim or an institutional claim. The claim edits for the carved out claims will be based on the Claim Edit library setup for the alternate payer. Parent topic: Configuring Alternate Payers

File Maintenance Help for NextGen® Enterprise 8

Carving Out Claims Based on Alternate Payer Configuration

The FQHC practices typically set up a payer in File Maintenance for UB claim (Medicare Part A) and associate an alternate payer to the payer (Medicare Part B) that carves out the SIM codes to a 1500 claim. This setup allows you to attach an insurance to the encounters of medicare patients that automatically splits the services to separate claims based on the SIM codes. You can carve-out charges into multiple electronic or paper claims based on the payer master setup. You can generate alternate payer claims based on the alternate payer billing options setup in the Payers-Alt Payers master file. You can either create a professional claim or an institutional claim. The claim edits for the carved out claims will be based on the Claim Edit library setup for the alternate payer. Parent topic: Configuring Alternate Payers

Help Guide for NextGen® Enterprise PM 8

Carving Out Claims Based on Alternate Payer Configuration

The FQHC practices typically set up a payer in File Maintenance for UB claim (Medicare Part A) and associate an alternate payer to the payer (Medicare Part B) that carves out the SIM codes to a 1500 claim. This setup allows you to attach an insurance to the encounters of medicare patients that automatically splits the services to separate claims based on the SIM codes. You can carve-out charges into multiple electronic or paper claims based on the payer master setup. You can generate alternate payer claims based on the alternate payer billing options setup in the Payers-Alt Payers master file. You can either create a professional claim or an institutional claim. The claim edits for the carved out claims will be based on the Claim Edit library setup for the alternate payer. Parent topic: Configuring Alternate Payers

File Maintenance Help for NextGen® Enterprise

Configuring Alternate Payers

The Alternate Payer Simultaneous Billing feature enables you to associate an alternate payer to a payer set up in the Payers master file. When you bill an encounter with a payer having multiple alternate payers, separate claims are generated simultaneously. The Alt Payer tab lists the alternate payer configurations for a payer. You can use the Alternate Payer Simultaneous Billing feature when the charges for an encounter should be billed to different payers (payer carve-out), usually on a different claim form type (1500 and UB). For example, you set up a payer to bill medical services such as an office visit (99213). Now, when you bill a behavioral health service for substance abuse therapy, the claim may go to a trading partner where the diagnosis is F11.10. But when the same substance abuse therapy is rendered for a patient with a mental health disorder, such as depression, the claim goes to the Department of Mental Health. Note: When you use the Alternate Payer Simultaneous Billing

Carving Out Claims Based on Alternate Payer Configuration

Recommendations

Create an Alternate Payer Carve-Out Criteria

Modify Alternate Payer Carve-Out Criteria

Carving Out Claims Based on Alternate Payer Configuration

Carving Out Claims Based on Alternate Payer Configuration

Carving Out Claims Based on Alternate Payer Configuration

Configuring Alternate Payers

Carving Out Claims Based on Alternate Payer Configuration

Create an Alternate Payer Carve-Out Criteria

Modify Alternate Payer Carve-Out Criteria

Carving Out Claims Based on Alternate Payer Configuration

Carving Out Claims Based on Alternate Payer Configuration

Carving Out Claims Based on Alternate Payer Configuration

Configuring Alternate Payers