Claim Header Rules and Claim Consolidation Rules

Help Guide for NextGen® Enterprise PM 8

Claim Header Rules and Claim Consolidation Rules

The physician with the highest-ranking specialty is automatically listed as the attending provider in the header data of the CSC claim. All CSC claims are sent to the payer as EDI files. These hierarchy rules will apply to all of the payers in the Valid Payers list. Establishing a Provider Hierarchy The following rules apply when setting up the provider hierarchy: The provider hierarchy is blank when creating a new library. A specialty can only display one time in the hierarchy. Specialties hidden in the Specialties master file do not display in the Select Responsible Attending Provider by Specialty list. You must select at least one specialty from the Select Responsible Attending Provider by Specialty list. When a Provider Hierarchy is NOT Established When a provider hierarchy is not established, in NextGen® Enterprise PM the user must enter a Primary Provider, for one of the encounters, in the Primary Responsible Attending field on the Consolidated Services Claim sub-tab on the Claim

File Maintenance Help for NextGen® Enterprise 8

Claim Header Rules and Claim Consolidation Rules

Use the Claim Header Rules tab to establish a provider hierarchy and identify the attending provider for consolidated service claims (CSC). The physician with the highest-ranking specialty is automatically listed as the attending provider in the header data of the CSC claim. All CSC claims are sent to the payer as EDI files. These hierarchy rules will apply to all of the payers in the Valid Payers list. Establishing a Provider Hierarchy When a Provider Hierarchy is NOT Established Add Claim Consolidation Rules to a CSC Library Add Claim Header Rules to a CSC Library Eligible Number of Patient Days Billing Parent topic: Consolidated Services Claim Library

Help Guide for NextGen® Enterprise PM 8

Claim Header Rules and Claim Consolidation Rules

Use the Claim Header Rules tab to establish a provider hierarchy and identify the attending provider for consolidated service claims (CSC). The physician with the highest-ranking specialty is automatically listed as the attending provider in the header data of the CSC claim. All CSC claims are sent to the payer as EDI files. These hierarchy rules will apply to all of the payers in the Valid Payers list. Establishing a Provider Hierarchy When a Provider Hierarchy is NOT Established Add Claim Consolidation Rules to a CSC Library Add Claim Header Rules to a CSC Library Eligible Number of Patient Days Billing Parent topic: Consolidated Service Claims

File Maintenance Help for NextGen® Enterprise

Add Claim Header Rules to a CSC Library

The Claim Header Rules establish a provider hierarchy and these hierarchy rules are applied to all the payers in the Valid Payers list. The physician with the highest-ranking specialty is automatically listed as the attending provider in the header data of the CSC claim. All CSC claims are sent to the payer as EDI files. In File Maintenance, select Libraries > Consolidated Services Claim. The Consolidated Services Claim List window opens. Select the applicable library. Select Open Menu , and then select Open. The Consolidated Services Claim Library Maintenance window opens. In Consolidated Services Claim Library Maintenance, select Open Menu , and then select Open. The Consolidated Services Claim Maintenance window opens. Select Claim Header Rules. In Select Responsible Attending Provider by Specialty, select Open Folder. The Attending Specialty Hierarchy window opens. In the Attending Specialty Hierarchy window, do one of the following: To add a specialty to the Included list, select

Help Guide for NextGen® Enterprise PM 8

Add Claim Header Rules to a CSC Library

The Claim Header Rules establish a provider hierarchy and these hierarchy rules are applied to all the payers in the Valid Payers list. The physician with the highest-ranking specialty is automatically listed as the attending provider in the header data of the CSC claim. All CSC claims are sent to the payer as EDI files. In File Maintenance, select Libraries > Consolidated Services Claim. The Consolidated Services Claim List window opens. Select the applicable library. Select Open Menu , and then select Open. The Consolidated Services Claim Library Maintenance window opens. In Consolidated Services Claim Library Maintenance, select Open Menu , and then select Open. The Consolidated Services Claim Maintenance window opens. Select Claim Header Rules. In Select Responsible Attending Provider by Specialty, select Open Folder. The Attending Specialty Hierarchy window opens. In the Attending Specialty Hierarchy window, do one of the following: To add a specialty to the Included list, select

Help Guide for NextGen® Enterprise PM 8

Add Claim Header Rules to a CSC Library

Access the Consolidated Services Claim Maintenance window for the applicable library. Note: To access a library, refer to the procedure Accessing a Consolidated Services Claim Library. Select the Claim Header Rules tab. In the Select Responsible Attending Provider by Specialty area, select Open Folder. The Attending Specialty Hierarchy window opens. On the Attending Specialty Hierarchy window, do one of the following: To add a specialty to the Included list, select the specialty in the Available list, and then select Include . The specialty moves from the Available list to the Included list. To remove a specialty from the Included list, select the specialty in the Included list, and then select Exclude . The specialty moves from the Included list to the Available list. Note: The list can be sorted numerically by selecting on Specialties column header or alphabetically by selecting the Description column header. Select OK. The Consolidated Services Claim Maintenance window displays with

Claim Header Rules and Claim Consolidation Rules

Establishing a Provider Hierarchy

When a Provider Hierarchy is NOT Established

Recommendations

Claim Header Rules and Claim Consolidation Rules

Claim Header Rules and Claim Consolidation Rules

Claim Header Rules and Claim Consolidation Rules

Add Claim Header Rules to a CSC Library

Add Claim Header Rules to a CSC Library

Add Claim Header Rules to a CSC Library

Claim Header Rules and Claim Consolidation Rules

Claim Header Rules and Claim Consolidation Rules

Claim Header Rules and Claim Consolidation Rules

Add Claim Header Rules to a CSC Library

Add Claim Header Rules to a CSC Library

Add Claim Header Rules to a CSC Library