Set Up the Primary Encounter Rate Tab

File Maintenance Help for NextGen® Enterprise 8

Set Up the General Tab

The General tab on the Encounter Rate Billing Library Maintenance window contains rules that apply when the ER payer is the primary, secondary, or tertiary payer on the encounter. Open the Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. On the General tab, set the general billing rule options as needed. Set the Encounter Rate Exempt setting. This setting applies only when one or more of the charge line SIM codes is flagged as Enc rate exempt in the Service Items library. The options are: Disqualify patient encounter from ER billing if: Select one of the following options to set the basis for disqualifying an encounter from encounter rate billing: All SIMs are ER exempt Only one SIM is ER exempt Suppress claim for disqualified patient encounter: Select this option to suppress the claim for any encounter that is disqualified from encounter rate billing based on exempt SIM codes. Select a Multiple Patient Encounters per day setting. This settin

File Maintenance Help for NextGen® Enterprise 8

Set Up the Claim SIM Options Tab

The Claim SIM Options tab on the Encounter Rate Billing Library Maintenance window contains options that provide the capability to show non-Encounter Rate SIMs on claims or affect automatic adjustments. Open an Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Claim SIM Options tab. In the Claim Service Range Options section, select open menu button and select New. The Alt Payer Number SIM Range window opens. Enter the SIM number or the beginning SIM number for a range of SIMs that you want to apply to a claim SIM option. For a range of SIM numbers, enter the ending SIM number. The ending SIM is required, but can be the same as the beginning SIM, functionally choosing that as a single SIM. Select OK. The claim SIM options are available for selection. Select the applicable option based on the following descriptions: Exclude from Encounter Rate Insertion: Select this option to make the service exempt from the Encounter Rate. This opti

File Maintenance Help for NextGen® Enterprise 8

Set Up the Claims Tab

The Claims tab on the Encounter Rate Billing Library Maintenance window contains a series of questions designed for configuring claims for the ER payer. Primary, secondary and tertiary claims for the payer can be configured separately. Open the Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Claims tab. Existing Claim Detail Rules sets display as separate rows, with the current active row at the top of the list. Rows can be sorted by selecting on the Eff Date, Exp Date or Description column headings. Do one of the following: To add a Claim Detail Rules set, select open menu button and select New. To modify a Claim Detail Rules set, select the row from the list, and then select open menu button and select Open. To copy a Claim Detail Rules set, select the row from the list, and select open menu button and select Copy. The Encounter Rate Claim Detail Rules window opens. In the Effective Date and Expiration Date fields, enter an effe

File Maintenance Help for NextGen® Enterprise 8

Set Up the Secondary and Tertiary Encounter Rate Tabs

The Secondary Encounter Rate and Tertiary Encounter Rate tabs on the Encounter Rate Billing Library Maintenance window contain billing rules that apply when the ER payer is the secondary or tertiary payer on the encounter. Open the Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Secondary Encounter Rate or Tertiary Encounter Rate tab. Select the Secondary Calculations when Medicare is the primary payer or Tertiary Calculations when Medicare is the primary payer settings for calculating the encounter rate when Medicare is the primary payer. The options are: Encounter Rate amount is equal to the: Select one of the following options to determine the calculation for the encounter rate of the secondary or tertiary payer when Medicare is the primary insurance. Encounter Rate minus Medicare allowed Medicare allowed minus Medicare paid Encounter Rate amount minus Medicare paid Medicare paid minus Encounter Rate amount Encounter Rate amoun

File Maintenance Help for NextGen® Enterprise 8

Set Up the COB Claims Tab

The COB Claims tab on the Encounter Rate Billing Library Maintenance window defines whether or not payers that may be subsequent to an encounter rate payer require the ER SIM code on their secondary/tertiary claims. For example, Medicare requires an Encounter Rate SIM code, or pay code, on qualified FQHC claims. Medicare then pays on that ER SIM. To create a balanced electronic secondary claim, the Medicare ER SIM must appear on the secondary claim with the appropriate CAS segments. In the case where the primary is an encounter rate payer and the secondary is not, but the secondary needs to see the ER SIM from the primary payer on the claim, the setup can be either of the following: Setup the Encounter Rate Library for the primary payer to insert the ER SIM as a charge, so the charge can be flagged to bill to the next payer. Setup the Encounter Rate Library for the primary payer to insert the ER SIM on Encounter Maintenance, and then setup an ER Library for the secondary payer to inser

Help Guide for NextGen® Enterprise PM 8

Set Up the Primary Encounter Rate Tab

The Primary Encounter Rate tab on the Encounter Rate Billing Library Maintenance window contains billing rules that apply when the ER payer is the primary on the encounter. Open the Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Primary Encounter Rate tab. Set the Suppress Claim Creation setting. The option is: Suppress claim for multiple same-day encounters (Multi-Yes only): Select this option to suppress the creation of a claim for an encounter with a status of Multi-no if there are multiple encounters per day. Set the Encounter Rate Calculation setting. The option is: Add 20% of original charge line items to encounter rate amount: Select this option to calculate 20% of the original charge amounts and add that to the encounter rate amount before inserting the new charge on the encounter. Set the Auto Adjustments settings. These settings have no impact on alternate payer charge lines. The option is: Adjust remaining balance of c

Set Up the Primary Encounter Rate Tab

Recommendations

Set Up the General Tab

Set Up the Claim SIM Options Tab

Set Up the Claims Tab

Set Up the Secondary and Tertiary Encounter Rate Tabs

Set Up the COB Claims Tab

Set Up the Primary Encounter Rate Tab

Set Up the General Tab

Set Up the Claim SIM Options Tab

Set Up the Claims Tab

Set Up the Secondary and Tertiary Encounter Rate Tabs

Set Up the COB Claims Tab

Set Up the Primary Encounter Rate Tab