| Claim Edit Library | Select the Claim Edits Library that you want to use for this payer. This selection overrides the default Claim Edits library selected in the Practice Preferences for Libraries. |
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| Type of Service Library | Select the appropriate Type of Service Library for the payer. |
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| Place of Service Library | Select the drop-down arrow and select the appropriate Place of Service Library for the payer. This enables you to attach a library with alternative place of service codes that are unique to this payer. |
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| Claim Print Library | Select the Claim Print Library that you want to use for this payer. When you change this field, a prompt displays to inform you that all existing claims for this payer in this practice will be changed. This selection overrides the default Claim Print library selected in the Practice Preferences for Libraries. |
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| Encounter Rate Library | Select the Encounter Rate library to assign to the payer. The Encounter Rate library controls the encounter rate SIM associated with the payer and the business rules that apply during billing.
Note: You can create or modify Encounter Rate Billing libraries.
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| Managed Care Contract | Select the contract from the Contract Library to associate with this payer. When you select a contract, you can then select which providers participate in the payer's plan. If you select a contract, the following fields become available: Participating Providers field, and the Prorate Insurance Balance, Transfer non-participating charges to patient, and Default Non-Participating provider's accept assignment to no check boxes. |
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| Participating Providers | If you make a selection in the Managed Care Contract field, the Participating Providers field automatically displays. If you have assigned contract subgroupings to providers and the subgrouping are linked to the contract you select, then the providers are automatically selected in the Participating Providers field. Select the drop-down arrow and select one or more rendering providers that are participating in the selected Managed Care Contract for this payer. |
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| Prorate Insurance Balance | This check box only displays if a contract library is selected in the Managed Care Contract field so you can opt to prorate insurance balances according to the contract's percentages. If this option is selected and it is also selected on the General tab of the Contract Maintenance window, then the patient's charges are prorated between the Primary Insurance and the Secondary or Patient bucket. Prorating is based on the Fee For Service percentages. You can view the prorated balances in the patient's balance control dialog box. |
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| Transfer non-participating charges to patient | Select this check box to transfer the primary insurance balance for a non-participating rendering provider to the patient bucket and skip any secondary or tertiary insurance attached to the encounter. This option requires that you select the Prorate Insurance Balance check box on both the Libraries tab and the General tab of the Contract library window. Once the initial claim is created for the primary insurance, the non-participating charge balance is moved to the patient bucket. By default, this check box is not selected.
Note: If you select this check box, the Patient Pmt Balance Reversal Reason Code check box becomes available on the Other tab of the Payers master file. When the patient has a balance and the applicable reason code is used to post the payment, the balance transfers to the secondary payer and is marked to rebill. This can only occur once for a patient's payment on each charge.
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| Default non-participating provider's accept assignment to no | Select this check box to set the default assignment of benefits to No for a specified encounter only for the insurance attached to that encounter when the rendering provider is a non-participating provider on the contract associated with the insurance. This check box is unchecked by default and only displays when a contract is selected in the Managed Care Contract field. When this option is selected, the first line in the Verification section of the Patient Chart - Encounters/Insurance tab will display Benefits NOT Assigned. In Addition, on the paper and electronic claim, Accept Assignment will be set to No. The Default Accept Assignment to No option always has priority over the Default Non-Participating Provider's Accept Assignment to No option. When the Default Accept Assignment to No option is selected, this option will automatically be checked and disabled. |
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| Remittance Profile Library | Select the Remittance Profile library to attach to the payer. This selection overrides the default Remittance Profile library selected in the Libraries Practice Preferences. |
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| Statement Library | Select the statement libraries to use when the associated payer is the primary, secondary, and tertiary payer.
Note: These payer-specific settings override the ones in the Statement Paramater Mappings master file.
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| Eligibility Profile Library | Select an Eligibility Profiles library to attach to the payer. The Eligibility Profiles library is required for submitting eligibility inquiries in batch mode. This library enables you to set up rules to automatically complete the required fields and additional data for batch mode that you would manually enter when running an eligibility status check in real-time mode. For more information, go to NextGen Healthcare Success Community and download the latest Eligibility Verification User Guide for NextGen® Enterprise PM. |
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| Claim Status Profile Library | Select a Claim Status Profiles library to attach to the payer. The Claim Status Profile library is required for submitting claim status inquiries. This library enables you to set up rules to automatically complete the required fields and additional data for batch mode processing. For more information, go to NextGen Healthcare Success Community and download the latest Eligibility Verification User Guide for NextGen® Enterprise PM. |
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| Modifiers Library | Select a Claims Modifier library to attach to the payer. This selection overrides the default Claim Modifiers library selected in the Libraries Practice Preferences. |
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| Behavioral Health Billing Library | Select a Behavioral Health Billing library to attach to the payer. If a Behavioral Health Billing Library is not defined at the payer level, then the system will use the library defined in the Libraries Practice Preferences. For more information about Behavioral Health Billing, go to NextGen Healthcare Success Community and download the latest Behavioral Health Billing User Guide for NextGen® Enterprise PM. |
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