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On the Payer tab in the Service Item library, all of the billing information displays that is needed to correctly set up the service item with a specific payer so that the claims are promptly paid.
| Field | Description |
|---|---|
| Payer | If a payer requires an alternate CPT4 or Revenue code for the service item, then select that payer name. If you need to set multiple payers, fill out the information for the first payer, then select a new payer. The window will clear, but the first payer's information is saved. |
| Suppress Rendering/ Attending Loop | You can select the option to determine whether the Attending (2310A) and Rendering (2310B) loops should be suppressed. |
| Do Not Sum Units for CPT4 Code | You can select this check box to indicate that for a specific payer and SIM combination,
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. |
| Single Unit CPT4 Code Roll Up | You can select the Single Unit CPT4 Code Roll Up check box if you want the application to roll up charges that are associated with the SIM's CPT4 code and have a quantity of 1 when claim is billed. |
| Single Unit Revenue Code Roll Up | You can select the Single Unit Revenue Code Roll Up check box if you want the application to roll up charges that are associated with the SIM's revenue code and have a quantity of 1 when the claim is billed. |
| Disable Patient Responsibility Percent | You can select this check box to disable the patient responsibility percent. |
| Send Operating Phys | You can select this check box to create the 2310B loop (Operating Physician) from the rendering provider on the claim. The 2310B loop is created on an electronic institutional claim (UB) for the selected SIM and payer combination. The loop is created even if the existing Populate Operating Physician Information if applicable option on the Submitter Profile library > Exception Options tab is deactivated. |
| Exclude Mods from Optical Management Charges | This check box only displays if you have a license for the NextGen® Optical Management application. If the current SIM is a NextGen® Optical Management SIM, you can select this check box to exclude the LT, RT, and RP modifiers from NextGen Optical Management charges. If this check box is clear, the SIM sends the modifiers from NextGen® Optical Management to NextGen® Enterprise PM. When the charges are sent without modifiers, the two charge rows with the same CPT4 code automatically bundle on the claim as one SIM with a quantity of 2. For more information, see the User Guide for NextGen® Optical Management. |
Suppress CPT from service line | You can select this check box to suppress the CPT4 code from the service line on institutional claims for the selected payer.
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| Force to Paper | You can select this check box to require the claims form type for claims generated for the payer to be paper. |
| Purchased Service | You can check this check box to designate a SIM as a Purchased Service Indicator for the selected payer. See Designating a SIM a Purchased Service Indicator for Specific Payers for additional information on billing rules and conditions for Purchased Service Indicators. |
| DME | You can check this check box to specify the SIM as a DME (Durable Medical Equipment) SIM for the payer. |
| Mammography Code | You can select this check box to specify the SIM as a Mammography code for the payer. |
| Qualifying Encounter | You can select this check box to specify the SIM as signifying that an encounter is a qualifying encounter for this payer. Any encounter that uses this SIM becomes a qualifying encounter.
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| Non Covered | You can select this check box to change the SIM to a non-covered charge. Non-covered charges report at the line item level on paper and electronic UB claims. The amounts display: on the paper form in FL-48 when you build a UB92 or UB04 claim with that SIM Item. in SV207 of the 2400 Loop when you generate the 837I. |
| Force Patient Responsibility | This setting only takes effect when it is selected for the primary payer. It is useful when you want to force the SIM to patient responsibility for individual payers.
Select this check box to assign the entire charge amount for the specified Service Item to the patient. This charge does not appear on the HCFA 1500, UB, or ADA forms. |
| Send Descriptor on EDI file | You can select this check box to use the narrative to populate the 2400 SV101-7 in the EDI file.
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| Also send narrative in NTE | You can select this check box to use the narrative to populate the NTE segment SV101-7 for DMERC. |
| Eff | You can enter the date that the alternate code becomes effective. |
| Exp | You can enter the date that the alternate code for the payer ends. |
| Form | You can select the HCFA 1500, ADA, or UB form.
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| Alt CPT4 | You can enter the alternate CPT4 code to be used. This must be a valid CPT4 code. If an alternate code is assigned, the Service Item displays on the charge window, but the ALT code prints on the claim. |
| Alt Payer CPT4 | You can enter the alternate CPT4 code to be used for an alternate payer. |
| Location | If the practice that the SIM has access to has multiple locations, select the location to use for this payer.
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| Alt Rev | You can enter the alternate revenue code. |
| Alt Mod 1-4 | These columns display if the SIM is selected as an anesthesia SIM on the General tab. If you enter one or more modifiers, then all existing modifiers are replaced when the SIM/payer combination is used during the billing process and that payer is either primary or secondary. It does not add the modifier if one does not already exist on the charge. The alt modifiers display on the claim but they do not display in charge entry.
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| Def Proc 1-6 | You can enter the default procedure codes to assign to the SIM, which will default into the procedural diagnosis box of the charge. These are the Level III diagnostic codes printed in boxes 80 and 81at the bottom of the UB92 or in boxes 74 and 71A-74E at the bottom of the UB04. |
| Def Condition Code | For UB SIMs, enter a default condition code to attach to the SIM. Then, during charge entry, the condition code becomes the default for the first empty UB condition code on the encounter when the SIM-payer and date range are valid. If there are no empty slots (for example, if you already have 7 condition codes), it does not do anything. |
| Alert Message | You can enter a message to display from the Charge Posting window as you add a charge for an encounter and select this SIM and a service date that falls between the effective and expiration dates for this SIM. |
| Force to Paper ICDs | You can select to select a diagnosis so that claims form type generate to paper for claims for this diagnosis and selected payer. |
When an alternate code is assigned, the service item displays in the charge window, but the ALT code prints on the claim.