Bill a Payer as Primary Regardless of Encounter COB

Help Guide for NextGen® Enterprise PM 8

Bill to a Primary Payer or a Prior Payer

A primary claim can be submitted to wrap payers to fulfill the payer’s requirement of submission as a primary claim even though they are actually secondary to an HMO or PPO. You can also bill these wrap claims simultaneously with the prior claim, which reduces the work required to manually flag charges for every encounter to bill both payers. For example, a secondary claim will bill with the primary and a tertiary claim will bill with the secondary one. When you set wrap payer claims to always bill as primary, data from other payers that might have been attached is omitted regardless of the encounter COB order. The wrap payers are typically Medicare and Medicaid wrap payers that remit a flat rate that is secondary to a primary HMO- or PPO-contracted primary payer. The payers can also be tertiary. Open the Payers master file and then select the Practice > Other tab. To have all claims for a payer bill as primary claims, select Always bill as primary. When selected, any paper or electron

File Maintenance Help for NextGen® Enterprise 8

Bill a Payer as Primary Regardless of Encounter COB

A primary claim can be submitted to wrap payers to fulfill the payer’s requirement of submission as a primary claim even though they are actually secondary to an HMO or PPO. You can also bill these wrap claims simultaneously with the primary claim, which reduces the work required to manually flag charges for every encounter to bill both payers. When you set wrap payer claims to always bill as primary, data from other payers that might have been attached is omitted regardless of the encounter COB order. The wrap payers are typically Medicare and Medicaid wrap payers that remit a flat rate that is secondary to a primary HMO- or PPO-contracted Primary payer. The payers can also be tertiary. You can also allow the wrap payer to be flagged to bill at charge entry with the primary payer. Open the Payers master file and then select the Practice > Other tab. To have all claims for a payer bill as primary claims, select Always bill as primary. When selected, any paper or electronic claims for t

File Maintenance Help for NextGen® Enterprise 8

Bill to a Primary Payer or a Prior Payer

A primary claim can be submitted to wrap payers to fulfill the payer’s requirement of submission as a primary claim even though they are actually secondary to an HMO or PPO. You can also bill these wrap claims simultaneously with the prior claim, which reduces the work required to manually flag charges for every encounter to bill both payers. For example, a secondary claim will bill with the primary and a tertiary claim will bill with the secondary one. When you set wrap payer claims to always bill as primary, data from other payers that might have been attached is omitted regardless of the encounter COB order. The wrap payers are typically Medicare and Medicaid wrap payers that remit a flat rate that is secondary to a primary HMO- or PPO-contracted primary payer. The payers can also be tertiary. Open the Payers master file and then select the Practice > Other tab. To have all claims for a payer bill as primary claims, select Always bill as primary. When selected, any paper or electron

Help Guide for NextGen® Enterprise PM 8

Configuring Alternate Payers

The Alternate Payer Simultaneous Billing feature enables you to associate an alternate payer to a payer set up in the Payers master file. When you bill an encounter with a payer having multiple alternate payers, separate claims are generated simultaneously. The Alt Payer tab lists the alternate payer configurations for a payer. You can use the Alternate Payer Simultaneous Billing feature when the charges for an encounter should be billed to different payers (payer carve-out), usually on a different claim form type (1500 and UB). For example, you set up a payer to bill medical services such as an office visit (99213). Now, when you bill a behavioral health service for substance abuse therapy, the claim may go to a trading partner where the diagnosis is F11.10. But when the same substance abuse therapy is rendered for a patient with a mental health disorder, such as depression, the claim goes to the Department of Mental Health. Note: When you use the Alternate Payer Simultaneous Billing

File Maintenance Help for NextGen® Enterprise 8

Configuring Alternate Payers

The Alternate Payer Simultaneous Billing feature enables you to associate an alternate payer to a payer set up in the Payers master file. When you bill an encounter with a payer having multiple alternate payers, separate claims are generated simultaneously. The Alt Payer tab lists the alternate payer configurations for a payer. You can use the Alternate Payer Simultaneous Billing feature when the charges for an encounter should be billed to different payers (payer carve-out), usually on a different claim form type (1500 and UB). For example, you set up a payer to bill medical services such as an office visit (99213). Now, when you bill a behavioral health service for substance abuse therapy, the claim may go to a trading partner where the diagnosis is F11.10. But when the same substance abuse therapy is rendered for a patient with a mental health disorder, such as depression, the claim goes to the Department of Mental Health. Note: When you use the Alternate Payer Simultaneous Billing

Help Guide for NextGen® Enterprise PM 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

Bill a Payer as Primary Regardless of Encounter COB

Recommendations

Bill to a Primary Payer or a Prior Payer

Bill a Payer as Primary Regardless of Encounter COB

Bill to a Primary Payer or a Prior Payer

Configuring Alternate Payers

Configuring Alternate Payers

Set Up the COB Claims Tab

Bill a Payer as Primary Regardless of Encounter COB

Bill to a Primary Payer or a Prior Payer

Bill a Payer as Primary Regardless of Encounter COB

Bill to a Primary Payer or a Prior Payer

Configuring Alternate Payers

Configuring Alternate Payers

Set Up the COB Claims Tab