Allowed and FFS/Balance Distribution

Field	Allowed and FFS/Balance Distribution Descriptions
Fee for Service	Enter the percentage of the full fee that you expect to get for participating and non-participating physicians.
% of Allowed Amount for Participants	Enter the percentage of the allowed amount a participating provider expects to be reimbursed. A provider is a participant when the contract is selected for it in the Providers master file.
% of Allowed Amount for Non-Participants	Enter the percentage of the allowed amount a non-participating provider expects to be reimbursed.
Prorate Insurance Balance	If this option is selected and it is also selected on Other tab (of Practice in the Add/Modify Payer Information window) then: The patient's charges will be prorated between the Primary Insurance and the Secondary or Patient bucket. The proration is based on the Fee for Service percentages. The prorated balances can be viewed in the patient's Balance Control window. Note: If you prorate the patient's charges, you can get a better idea of your true Account Receivable status. Your reports will reflect the true percentage that you expect to get from each of your insurance companies, rather than showing it all under the primary payer. Note: When the Prorate Insurance Balance option is checked, balances are allocated to responsible parties based on the % of Allowed Amount for the option or the specifics of a CPT4 line item. This selection works in conjunction with the Prorate Insurance Balance option Fee for Service on the Payer master file.
Enable Drug Allowed Amount	If you bill drug codes to Medicare and want to see three digits display after the decimal in the Allowed column on the Contract Library Maintenance Fee Schedule tab, select this check box. For example, 20.244 instead of 20.24. The Reimbursed columns also display with three digits because they are based on the Allowed column amounts. Note: The Medicare Part B Drug Average Sales Price (ASP) drug pricing files use three digits.
Fully Capitated	Select this option to automatically adjust off the total charge on the claim. To activate this function you must: select the option Default contract amounts when payer selected on the Transaction window in the Practice Preferences. The adjusted amount appears in the Adj column on the Transaction window.
Produce Claim for documentation	Select this check box to print a claim.

Help Guide for NextGen® Enterprise PM 8

Automatic Adjustments

The Automatic Adjustments section enables you to automatically adjust charges to the expected allowed amount at the time they are entered. This section is used in conjunction with the Fee Schedule tab. Field Automatic Adjustments Descriptions Automatically adjust charges Select this check box so that adjustments are automatically made for the items at the time charges are entered on the Charge Posting window. This check box enables the remaining fields in the section. Adjustable Allowed Amount Select this check box to determine the write off (auto adjustment) based on the patient co-pay plus the contract reimbursement amount. If you select this option, the Co-Pay Origin field changes to Reimbursed and, on the Fee Schedule tab, the Allowed column becomes disabled. Default Auto-Adj Transaction Select the transaction code to associate with the automatic transactions. Note: The codes listed are set up in the Transaction Codes master file as an Adjustment type and have the source as Third p

Help Guide for NextGen® Enterprise PM 8

Contract Defaults

The Contract Defaults section contains options that enable you to set informational alerts, information about co-payments, co-pay amounts, and a default percentage for expected reimbursement, among other options. Field Contract Defaults - Contractor and Co-Pay Options Descriptions Co-Payment on Office Encounters To require a co-payment, select this check box. When you attach insurance to an encounter, an alert reminds you that the contract requires a co-pay for all encounters. Default Co-Pay Amount Indicates the dollar amount of the default co-payment for all office encounters. This amount becomes the default in the Insurance Maintenance window for any patients that have insurance associated with this contract. When entering insurance information for the patient, you will be warned that a co-payment is required. Also, when you attach the insurance to the encounter, you will be given another warning. Co-Pay Origin Select either Allowed or Reimbursed to determine whether the co-pay perce

File Maintenance Help for NextGen® Enterprise 8

Allowed and FFS/Balance Distribution

Field Allowed and FFS/Balance Distribution Descriptions Fee for Service Enter the percentage of the full fee that you expect to get for participating and non-participating physicians. % of Allowed Amount for Participants Enter the percentage of the allowed amount a participating provider expects to be reimbursed. A provider is a participant when the contract is selected for it in the Providers master file. % of Allowed Amount for Non-Participants Enter the percentage of the allowed amount a non-participating provider expects to be reimbursed. Prorate Insurance Balance If this option is selected and it is also selected on Other tab (of Practice in the Add/Modify Payer Information window) then: The patient's charges will be prorated between the Primary Insurance and the Secondary or Patient bucket. The proration is based on the Fee for Service percentages. The prorated balances can be viewed in the patient's Balance Control window. Note: If you prorate the patient's charges, you can get

Help Guide for NextGen® Enterprise PM 8

Prorating Charge Balances using Balance Control

You can prorate the charge balances on an encounter between the primary and secondary insurances, or between the primary insurance and patient if no secondary insurance exists. The prorated amount is based on the fee for service allowed amount and reimbursed % defined in the fee schedule for the contract linked to the primary payer. The prorate functionality works only if the Prorate Insurance Balance check box is selected in the following areas in File Maintenance: Contracts > General tab Payers > Practice tab, Libraries sub-tab Example: A contract is set up for Medicare with fee schedule parameters as follows: CPT Code Charge Amount Allowed Amount Reimbursed % 99213 $100.00 $90.00 80% 81002 $35.00 $20.00 80% 82962 $35.00 $20.00 80% When you enter the above charges on an encounter where Medicare is the primary payer, the charges balances are automatically prorated so that 20% of the Allowed Amount moves to the Ins2 Amt bucket in Balance Control. If there is no secondary insurance on t

File Maintenance Help for NextGen® Enterprise 8

Set Up Auto Charge Adjustments for Non-Participating Providers

Before you begin For the Contract's auto-charge adjustment to work properly, you must populate the following fields on the General tab of the Contract Library Maintenance window: Add a value to the % of Allowed Amount for NonParticipants field Select the Automatically adjust charges check box The application enables you to set up auto-adjustments for non-participating providers based on the terms of their contract. When charges are entered, they are adjusted according to the terms of the contract for the non-participating providers. In File Maintenance, access the Payers Master File. The Payer List window appears. Select the open menu button and select New to set up a new payer or select Open to modify an existing payer. The Add/Modify Payer Information window appears. Select the Practice tab and then select the Libraries tab. Select the drop-down arrow in the Managed Care Contract field and select the contract that meets the contract terms of the payer. When you select a contract, the

Help Guide for NextGen® Enterprise PM 8

Set Up Auto Charge Adjustments for Non-Participating Providers

Before you begin For the Contract's auto-charge adjustment to work properly, you must populate the following fields on the General tab of the Contract Library Maintenance window: Add a value to the % of Allowed Amount for NonParticipants field Select the Automatically adjust charges check box The application enables you to set up auto-adjustments for non-participating providers based on the terms of their contract. When charges are entered, they are adjusted according to the terms of the contract for the non-participating providers. In File Maintenance, access the Payers Master File. The Payer List window appears. Select the open menu button and select New to set up a new payer or select Open to modify an existing payer. The Add/Modify Payer Information window appears. Select the Practice tab and then select the Libraries tab. Select the drop-down arrow in the Managed Care Contract field and select the contract that meets the contract terms of the payer. When you select a contract, the

Allowed and FFS/Balance Distribution

Recommendations

Automatic Adjustments

Contract Defaults

Allowed and FFS/Balance Distribution

Prorating Charge Balances using Balance Control

Set Up Auto Charge Adjustments for Non-Participating Providers

Set Up Auto Charge Adjustments for Non-Participating Providers

Automatic Adjustments

Contract Defaults

Allowed and FFS/Balance Distribution

Prorating Charge Balances using Balance Control

Set Up Auto Charge Adjustments for Non-Participating Providers

Set Up Auto Charge Adjustments for Non-Participating Providers