Defaults 2 Sub-Tab

The following table describes the options and settings available on the Defaults 2 tab in the Defaults - 2 tab for a payer.

Field

Description

Diag Codes (Diagnosis Codes)

Enter one of the following:

Y to indicate that the payer requires diagnosis codes.
N to indicate that the payer does not require diagnosis codes.

Lab Fac

Enter the laboratory facility.

Rad Fac

Enter the radiology facility.

Def Accpt Asgn

This is Default Accept Assignment, the default assignment of benefits for the provider. Enter one of the following:

Y to pay the provider.
N to pay the guarantor.

Def Deductible

Enter the default deductible amount that must be met before benefits can be paid.

Formulary Provider

Enables you to add a formulary to the payer.

Note

Enter additional information, if needed.

Cross-over

If this check box is enabled, the payer is identified as a Medicare secondary automatic crossover payer if set up as secondary payer. The payer may also serve as the primary payer.

Disable diagnosis claim break

Note: You can also set this option at the practice level in the Claims Practice Preferences.

Dental payer

Enable this check box to designate the payer as a Dental Payer. To bill dental SIMs and create ADA Dental claims, a dental payer must be attached to the encounter.

Note:

If an encounter is billed with dental service items and a Dental Payer is not attached to the encounter, then those charges automatically skip the payers attached and become the patient’s responsibility.

If this check box is enabled and the appropriate insurance is selected for an encounter, the plan is marked as Dental on the ADA form.

Require Policy Number

Enable this check box to require a policy number on the Insurance Maintenance window at the patient level.

Do Not Sum Units for CPT4 Code

Enable this check box to indicate that for this payer, multiple identical charge lines are prevented from being combined on one line and summed on the paper claim. The identical charges display on separate lines on the paper HCFA 1500 claim or are entered individually in an electronic send file. When the check box is cleared (the application default), the application sums identical line items and indicates multiple units for billing on a paper HCFA 1500 or in an electronic send file. Multiple identical charge lines are prevented from being combined on one line and summed on the paper claim. The identical charges display on separate lines on the paper HCFA 1500 claim or are entered individually in an electronic send file. When the check box is cleared (the application default), the application sums identical line items and indicates multiple units for billing on a paper HCFA 1500 or in an electronic send file.

Note: You can also set this option at the SIM or practice levels.

Require override policy number

Enable this check box to require the override policy number when users add this payer to an encounter for a patient that is not the guarantor.

Eligibility\Referral Support

Select this option to use the same payer across all practices in the enterprise for eligibility and referrals rather than selecting the Eligibility Support and Referral Support check boxes in the Other tab of the Practice tab on the Payers master file for each payer.

Send Prior Payer ICN on COB Claims

For COB claims, select this check box to:

Produce one claim for multiple line items with the same ICN
Produce separate claims for line-items with different ICNs
Populate the Prior Payer Resubmission Reference Number field in Claim Maintenance on the Claim Header tab. The ICN is returned in the 2100-CLP07 loop during ERA processing or can be entered manually in the Resub code on the transaction.
Create the 2330B /ref (F8 qualifier) on COB claims.

Note: If prior to upgrade, the Send Medicare ICN on COB Claims check box was selected, then the Send Prior Payer ICN on COB Claims check box will be enabled.

Display override policy number and co-pay

Select this check box to allow the entry of a patient's co-pay that is different from the insured's co-pay. When this box is selected, the override policy number and co-pay fields for the patient display on the Insurance Maintenance window below the Practice Level section. This allows you to override the co-pay set up at the practice or enterprise level.

When a dependent has an encounter created, his or her policy number prints in box 1A of the HCFA 1500 and the subscriber's name prints in box 4.

Disable supervisor billing

Select this check box to disable supervisor billing for a specific payer. This setting overrides similar supervisor billing settings at the practice-provider level located in the Practice tab of the Provider master file.

Require group number

Select this check box to require a group number on the Insurance Maintenance window at the patient level.

Suppress zero balance claims

Select this check box to suppress claims with a $0 (zero) balance during batch biling.

Display provider payer Loc ID

Select this check box to display the Loc ID field in the Group Information section of the Practice tab of the Add/Modify Provider window for a specific provider.

CPT on Rev Code Roll-up

Select this option to pull the first CPT4 code from the charge for the SIM that is set up as a Revenue Code Rollup in the Payer tab of the SIM Library. This option is used for both electronic (in SV202 in the 837I) and paper (in FL 44 on the UB) claims.

Force drug code claim break

Select this option to create a separate claim when charges are found with an associated NDC code.

Add tax line item per service line

Select this check box to define that, for this payer, the tax rate will be applied at the line item level. Tax rates are determined by settings in the Tax Rate library.

Send ICN on Resubmission

Select this check box to do the following:

Produces one claim for resubmissions or COBs with multiple line items and the same ICN.
Produces separate claims for line-items with different ICNs
Populates Loop 2300 REF F8 qualifier with the ICN.
Populates the resubmission_reference_nbr in the Transaction when returned from the Loop 2100 Segment CLP07 in the ERA file or manually entered in the Resub# field on the transaction header.
Populates the ICN number in Claim Maintenance and in the EDI file when an encounter is rebilled to a corresponding payer.

Note:

If prior to upgrade the ICN Number check box...	Then on upgrade...
is selected	the check box is selected.
is NOT selected	the check box IS NOT selected.
is NOT selected and an encounter is rebilled to a corresponding payer	the ICN number is populated only on the Resubmission Reference Number field in the Claim Header tab of the Claim Maintenance.

Policy Number Format

Select the drop-down arrow to select the required format for entering the policy number on the Insurance Maintenance window.

The formats listed in this field are created in the Formats master file..

Group Number Format

Select the drop-down arrow to select the required format for entering the group number on the Insurance Maintenance window.

The formats listed in this field are created in the Formats master file.

SubGrouping One (User-defined field)

Select one of the payer subgrouping category types that you want to use as a reporting filter for this payer.

Note: You can change the name of this field in the Payer Subgrouping 1 field on the General tab of the Enterprise Preferences window.

SubGrouping Two (User-defined field)

Select one of the payer subgrouping category types that you want to use as a reporting filter for this payer.

Note: You can change the name of this field in the Payer Subgrouping 2 field on the General tab of the Enterprise Preferences window.

Medication Payer Group

Select the Medication Payer Group from the drop-down list to use as the default for your Enterprise. By selecting a Medication Payer Group, you can verify medications at the payer level.

The groups listed in this field are created in the Medications by Payer Group master file for NextGen® Enterprise EHR .

Default Resubmission Code

Set the default code for the resubmission number to one of the following:

Corrected (6) Adjustment of Prior Claim
Replacement (7) Replacement of Prior Claim
Void (8) Void/Cancel of Prior Claim

Turn Off Edits

Select this check box to prevent the Edits process from being run when an encounter is being billed to this payer. Use this option carefully because dirty claims could result.

Prevent modifying plan name on Insurance Maintenance

Select this check box to prevent the changing of the payer's plan name in the Plan Name field on the Insurance Maintenance window in NextGen® Enterprise PM.

Disable sliding fee adjustments when primary

Select this check box to prevent sliding fee adjustments from being taken when the payer is primary.

Note: If you want to prevent sliding fee adjustments for all encounters that have insurance attached, select Disable Sliding Fee Adjustments for encounters with insurance attached in the Sliding Fee practice preferences.

Populate claim prescription number with claim ID number

Select this option to automatically populate the prescription number for any claim detail records on the claim with the claim ID number. This number is the system-assigned Claim ID. For pharmacy claims this is the value that is subsequently returned back from the payer and so it can be used in ERA.

Contracted payer

Select this check box to indicate that the payer is contracted and, therefore, receives different discounts from what a non-contracted payer receives.

Note:

When you create new payers, this check box is not selected.
The contracted payer indicator is available in NextGen® Enterprise EHR for templates.
This check box is not related to the Contracts library or to contracts.

For more information about setting up discounts, see Automating Discounts for Payers.

Claim charges limit

Enter a number or use the up and down arrows to set the maximum number of charges to send for each claim in the electronic send file.

Patient control number digits

Use the up and down arrows to set the number of digits that make up the Patient Control Number. You can also highlight the field and enter the number of digits directly. This feature enables you to match the length of Patient Control Numbers to the requirements of specific payers for claims.

Send Diagnosis Mappings on Claims

Specify which diagnoses to send on the claim if the payer cannot accept ICD-10 codes and needs ICD-10 mappings to ICD-9 codes instead of the standard ICD-10 codes. The codes in the mapping options are defined in the Diagnosis Codes library.

Select this check box, and then select one of the following options:

None - Use no mappings.
General Mappings only – Use the general mappings.
Payer Mappings only – Use the payer mappings.
Payer Mappings, else General Mappings – To perform alternate diagnosis code (Alt Dx) mapping on the Charge Entry window. This feature allows you to map an ICD-10 code to an ICD-9 code for non-HIPAA entities.

If the check box is not selected, then the standard diagnosis codes stored in charge entry and the encounter diagnosis module will be sent on the claim.

Payer Alert

Enter a message that you want to display about the payer. This message can be set to display during the check-in or check-out process in the Alerts Practice Preferences.

Defaults 2 Sub-Tab

Recommendations

Defaults 2 Sub-Tab

Defaults-2 Tab

Payer Tab - SIM Library

Configurations in Claim Practice Preferences

Configurations in Claim Practice Preferences

ADA (2019 and 2024) Form Options For Primary Payer

Defaults 2 Sub-Tab

Defaults-2 Tab

Payer Tab - SIM Library

Configurations in Claim Practice Preferences

Configurations in Claim Practice Preferences

ADA (2019 and 2024) Form Options For Primary Payer