Add or Modify an Encounter Rate Billing Library

Help Guide for NextGen® Enterprise PM 8

Add or Modify SIM Codes for Encounter Rate Billing

In the Service Items library, you must create an Encounter Rate SIM code for each Encounter Rate CPT4 code. To add or modify a SIM code for encounter rate billing, do the following: Access File Maintenance. Select Libraries, and then Service Items. The Service Items List window opens. From the list, select a library and then select Open Menu and select Open. The Service Item Library Maintenance window opens. Do one of the following: To add an Encounter Rate SIM code, select Open Menu and select New. To modify an Encounter Rate SIM code, search for the code and then select the code from the list on the left. Service Item Library Maintenance In the CPT4 Code field, enter the encounter rate CPT4 code and then press Tab. In the two Modifier fields, press Tab to leave the fields blank. The Service Item # field automatically defaults to the encounter rate CPT4 code. Press Tab. The Description field automatically defaults to the description for the encounter rate CPT4 code. Press Tab. On the

Help Guide for NextGen® Enterprise PM 8

Set Up Payers for Encounter Rate Billing

Once the Encounter Rate Billing library has been created, it must be attached to the appropriate encounter rate payers. Attaching the Encounter Rate Billing library ensures that during the billing process in NextGen® Enterprise PM, the ER SIM code is inserted onto the encounter and the claim is configured correctly to meet the ER payer's specific requirements. Access File Maintenance. Select System Master Files, then PM, and then Payers. The Payers List window opens. From the list, select an ER payer, and then select Open Menu and select Open. The Modify Payer Information window opens. Select the Practice tab, and then select the Libraries sub-tab. In the Encounter Rate Library field, select the Encounter Rate Billing library for the payer. Modify Payer Information To save changes and close the window, select OK. Parent topic: Setting Up Encounter Rate Billing

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

File Maintenance Help for NextGen® Enterprise 8

Add or Modify an Encounter Rate Billing Library

Before you begin A SIM with the appropriate CPT4 code must be set up in the SIM Library before you set up encounter rate billing. Note: When you copy an Encounter Rate Billing Library, the SIM configuration hierarchy and the encounter rate information are also copied. Encounter Rate Billing Library provides flexibility to set up multiple rate codes to accommodate different billing requirements of individual payers. You can generate both Encounter Rate Library Listing and Encounter Rate Library with Claim Detail Rules reports from the Encounter Rate Billing Library. For more information, go to NextGen Healthcare Success Community and download the latest Reports User Guide forNextGen®Enterprise PM. To add or modify an Encounter Rate Billing Library, do the following: Open File Maintenance. Select Libraries > Encounter Rate Billing. The Encounter Rate Billing List window opens. Do one of the following: To add a library, select the open menu button and then select New. To modify a library,

Help Guide for NextGen® Enterprise PM 8

Set Up Encounter Rate SIM Maintenance Configurations

After you set the SIM configuration hierarchy, you must set up specific parameters for the encounter rate SIM code. Open File Maintenance. Select Libraries > Encounter Rate Billing. The Encounter Rate Billing List window opens. Select a library from the list. The Encounter Rate Billing Library Maintenance window opens. Right-click the Encounter Rate SIM grid, and then select New. The Encounter Rate SIM Maintenance window opens. Encounter Rate SIM Maintenance window Enter the service item number. Select the effective and expiration dates. Enter the co-pay amount. Select a condition code for Field Locator 18 on UB claims. Note: The Description and Amount fields are automatically filled in based on the service item description for the encounter and the corresponding dollar value from the SIM. You can modify the values. Optional: In the Required CPT4 section, select the open record button, and then select the codes. Select the payer in COB. Optional: In the Valid Primary Payers section, se

Help Guide for NextGen® Enterprise PM 8

Set the SIM Configuration Hierarchy

Before you build an encounter rate, you must configure your hierarchy for diagnosis code, CPT4 code, location, provider, sex, and age. NextGen® Enterprise PM uses this hierarchy to determine which encounter rate SIM to use during billing. For example, if diagnosis has a higher position in the hierarchy than location, the application uses an Encounter Rate SIM that applies to a specific diagnosis for all locations instead of an encounter rate that applies to all diagnoses for a specific location. Note: In most cases, the default hierarchy does not need to be changed. Open the Encounter Rate Billing library. The Encounter Rate Billing List window opens. Select the Open Menu button and select New. The Encounter Rate Billing Library Maintenance window opens. Encounter Rate Billing Library Maintenance In the Encounter Rate SIM section, select the Set Configuration Hierarchy button. The SIM Configuration Hierarchy window appears. The hierarchy is set from the top down. SIM Configuration Hier

Add or Modify an Encounter Rate Billing Library

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