Activate a Claim Edit to Require Case Management

Help Guide for NextGen® Enterprise PM 8

Require Case Management for a Payer

You can indicate that a payer requires case management in NextGen® Enterprise PM. The payer can then only be used on encounters that are part of a case. When case management is required, the following occurs: The Case Management Required field displays on the Patient Chart > Encounters tab > Case Management tab. If a user selects insurance for an encounter and a case is not attached to the encounter, then a warning alert displays when a user saves the encounter insurance. To generate a claim edit when the payer is attached and the encounter is not linked to a case, activate claim edit 217. In File Maintenance, select Master Files > System > Payers. Double-click a payer. The Modify Payer Information window opens. Select Practice tab > Other tab. Select Require Case Management, and then select OK. Select Require Case Management, and then select OK. If you want to generate a claim edit when the payer is attached but the encounter is not linked to a case, activate claim edit 217. Parent to

Help Guide for NextGen® Enterprise PM 8

Apply a Case Type to a Case

A Case Type indicates the nature of a case and determines how a case is handled. A Case Type is further defined by a category. For example, if you create a case type named Private, you can assign case categories such as: Mobile Services, 24 Hour Nurse Triage, Urgent Care, Consulting, CMCA, and None. In File Maintenance, access the Master Files > System > Case Type. The Case Type List windows opens. Do one of the following: To add a new item, select the open menu icon and select New. To modify an existing item, select the item in the list, select the open menu icon and then select Open. Alternatively, you can double-click to open the item. The Add Case Type Information window opens. For Category, enter a name for the case type. Examples of case type are: Workers Compensation Injury, Non-Injury, Private, and Group Health. For Short Description, enter a four-character description. If the case type has categories, select to modify the Case Type Categories associated with the case type. The

Help Guide for NextGen® Enterprise PM 8

Activate Claim Edits

The Claim Edits Library contains a list of the available claim edits you can apply to the claims you generate. In File Maintenance, select Libraries > Claim Edits and select the applicable Claim Edits Library. The Claim Edit Library Maintenance window opens. Select the claim edit you want to activate by selecting in the Active column. A check mark displays to indicate the claim edit is active. To edit the Help Text, select the Help Text field and enter the new description for the Help Text. To change the edit severity level, select in the Severity field, and select one of the following severity levels: Warning Critical Custom Required After you make your selections, select OK. Parent topic: Claim Edits Library

Help Guide for NextGen® Enterprise PM 8

Case Management Setup

Setting up Case Management involves the following: Grant the necessary user rights and permissions in System Administrator. Enable Case Management in File Maintenance. Set alerts. Add case information to: Fee tickets Form and label templates from the data repository Requires a case on an encounter. Activate claim edits. Set up the Case Type Master. File in the File Maintenance. Set up and populate the Case Category, Case Contact Role, and Case Market in Master Lists in File Maintenance. Restrict user access to case management in System Administrator. If you use template editor, create the appropriate Case Management Templates in Template Editor. This involves setting the following General Options universal preferences in the System Administrator application that enable you to map template field names to case level templates: Case Mgt Case Type Category Field Case Mgt Case Type Category Item Field Case Mgt Market Field Enable consolidation of claims related to a Clinical Episode of care

Help Guide for NextGen® Enterprise PM 8

Claim Edits Library

Claim edits are a set of conditions that must be (or are suggested to be) met when you generate a claim. For example, is the patient's zip code required in the claim? Must the referring physician's first name appear on the claim? These are the kinds of requirements you can set up to control the information that appears in the claims you generate. The Claim Edits Libraries enable you to select the claim edits to run when billing encounters and generating claims. A default Claim Edits Library must be created and attached at the Practice Preferences level before you can bill encounters and generate claims. After, a default library is created and attached at the Practice Preferences level, you can then create payer-specific Claim Edits Libraries and attach them at the Payer Master level. These payer-specific claim edits libraries override the default Claim Edits Library. The application maintains a list of available claim edits in the Claim Edits Library, which you can access within File M

Help Guide for NextGen® Enterprise PM 8

Set Up Claim Edits for Encounter Rate Billing

When an encounter is billed in NextGen® Enterprise PM, auto-adjustments are applied to the original charges based on parameters defined in the Encounter Rate Billing library. For most Medicaid (non-Medi-Cal) payers, the first charge on the encounter is auto-adjusted to a balance equal to Medicaid's encounter rate, and all other charges are auto-adjusted to a balance of $0.00. All charges, including the $0.00 balance charges, must appear on the claim for Medicaid. To accomplish this, claim edit #97 must be deactivated in the Claim Edits library used for Medicaid. Note: A default Medicaid Claim Edits library comes pre-installed. It is suggested that Claim Edit #97 be deactivated in this library, and then attach the library to Medicaid (non-Medi-Cal) payers. Access File Maintenance. Select Libraries, and then Claim Edits. The Claim Edits List window opens. From the list, select a library and then select Open Menu and select Open. The Claim Edit Library Maintenance window opens. Select the

Activate a Claim Edit to Require Case Management

Recommendations

Require Case Management for a Payer

Apply a Case Type to a Case

Activate Claim Edits

Case Management Setup

Claim Edits Library

Set Up Claim Edits for Encounter Rate Billing

Require Case Management for a Payer

Apply a Case Type to a Case

Activate Claim Edits

Case Management Setup

Claim Edits Library

Set Up Claim Edits for Encounter Rate Billing