NextGen Knowledge Center

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.

  1. Open the Payers master file and then select the Practice > Other tab.

  2. To have all claims for a payer bill as primary claims, select Always bill as primary.
    When selected, any paper or electronic claims for the payer bill as primary claims even if the payer is attached to the encounter as secondary or tertiary. These claims will create as if this payer is the only payer on the encounter and they omit any references to other payers from the encounter, charges, or transactions. The resulting claim is as if this payer is primary on the encounter with no other payers attached.
    • Resulting electronic claims (professional or institutional) have no Other Subscriber or Other Payer information (2320 loop or 2330 loop). This applies to the primary payment and adjustment information as well (2320 segments, 2330 segments, 2400 AMT*AAE, 2400 AMT*B6 or the 2430 loop).
    • Resulting paper claims have no reference to another payer in boxes 9 - 9d or 11d for 1500 or in FL50 - 65 for UB04.
  3. To flag this wrap payer to bill at charge entry, select the Bill with primary check box.
    Enabling this option automatically inserts a green check mark for the payer in the R column, regardless of COB, along with COB1 at charge entry and allows the claim to create simultaneously with the primary claim.
    • This will automate flagging to bill and reduce the time required to manually flag these charges by using Balance Control.
    • The Bill with primary check box is not tied to Always bill as Primary. If Bill with primary is enabled without Always bill as Primary, a true secondary claim is created for the secondary payer even though adjudication information will not be available to include in the secondary claim. This situation causes the secondary payer bucket to flag even if the primary payment has not been received. Use of this option alone should only be used for Medi-Cal.