Claim Consolidation Rules

Field	Description
Claim Form Type	To enable claims consolidation select one of the following options: 837P/1500 837I/UB Both
Encounter Rate Claims	Select one or both of these options to consolidate encounter rate claims: Consolidate Encounter Rate claims only. Consolidate only claims with the same Encounter Rate SIM. A green check mark appears in these fields.
Consolidate Encounter Rate SIM Service Line
Rollup Encounter Rate Service Line	In this field select either: No - encounter rate SIM claims will not be consolidated. The remaining fields are not available. Yes - to consolidate encounter rate SIM claims. Complete the fields that are active for the selected timespan.
Encounter Rate SIM Quarterly
Same Day Claims	Select either: Sum of ER Service Lines 1
Weekly Claims	The default value in this field is 1. The value cannot be changed.
Monthly Claims	Select either: 1 Sum of ER Service Lines Number of Eligible Patient Days Number of Days in the Month
Case Claims	Select either: Sum of ER Service Lines 1
Encounter Rate Service Line Amount
Same Day Claims	Select either: Sum of ER Line Amounts Original Charge Amount
Weekly Claims	Select either: Sum of ER Line Amounts Original Charge Amount
Monthly Claims	Select either: Sum of ER Line Amounts Original Charge Amount Number of Eligible Patient Days
Case Claims	Select either: Sum of ER Line Amounts Original Charge Amount
Encounter Rate Service Line Dates of Service - From Date and To Date
Same Day Claims	These fields are not available.
Weekly Claims	Select either: Sunday - Saturday Monday - Sunday
Monthly Claims	Select one of the following: First Date of Service and Last Date of Service First Date of Eligibility and Last Date of Eligibility First Day of the Month and Last Day of the Month
Case Claims	Select either: First Date of Eligibility and Last Date of Eligibility First Encounter Date and Last Encounter Date

Help Guide for NextGen® Enterprise PM 8

Add Claim Consolidation Rules to a CSC Library

To enable claims consolidation, you must select the form types that you want to consolidate. Then you can choose to consolidate only encounter rate claims and/or claims with the same encounter rate SIM. These rules will apply to all of the payers in the Valid Payers list. Access the Consolidated Services Claim Maintenance window for the applicable library. Note: To access a CSC library, refer to the Accessing a Consolidated Services Claim Library procedure. After opening the Consolidated Services Claim Maintenance window, select a valid payer for the claim, then Claim Consolidation Rules. From the Claims Consolidation Rules tab, select a Claim Consolidation Rules row (CCR row) and open by doing one of the following: Right-click the library and select Open. Select the open menu button and select Open. The CSC Timespan Rules window opens for the library you selected. Complete the timespan rules. Note: When creating a new library, the Claim Consolidation Rules row (CCR row) is not require

File Maintenance Help for NextGen® Enterprise 8

Claim Consolidation Rules

The following table lists the claim consolidation rules to be set for a selected time span. Field Description Claim Form Type To enable claims consolidation select one of the following options: 837P/1500 837I/UB Both Encounter Rate Claims Select one or both of these options to consolidate encounter rate claims: Consolidate Encounter Rate claims only. Consolidate only claims with the same Encounter Rate SIM. A green check mark appears in these fields. Consolidate Encounter Rate SIM Service Line Rollup Encounter Rate Service Line In this field select either: No - encounter rate SIM claims will not be consolidated. The remaining fields are not available. Yes - to consolidate encounter rate SIM claims. Complete the fields that are active for the selected timespan. Encounter Rate SIM Quarterly Same Day Claims Select either: Sum of ER Service Lines 1 Weekly Claims The default value in this field is 1. The value cannot be changed. Monthly Claims Select either: 1 Sum of ER Service Lines Number

Help Guide for NextGen® Enterprise PM 8

Set Up Rules for Consolidation of Case Claims

To set up rules for consolidation of claim on a case basis, you can choose the claim form type, rollup encounter rate service lines, and identify dates of services for encounters. In File Maintenance, select Libraries > Consolidated Services Claim and then double-click the applicable library. The Consolidated Services Claim Library window opens. Select open menu , and then select New or Open. The Consolidated Services Claim Maintenance window opens. To access the Payers window, select the Valid Payer folder icon, and then select the valid payers for case consolidation of claims. To access the CSC Timespan Rules window, on the Claim Consolidation Rules tab, Select open menu . In the Length of Timespan field, select Consolidate Case Claims. In the Description field, enter a description for the consolidation of case claims. Use the following table as a reference to add or modify case claim consolidation rules: Note: The claim consolidation rules are applied to all payers in the Valid Paye

Help Guide for NextGen® Enterprise PM 8

Set Up for Eligible Number of Patient Days Billing

Access File Maintenance. Select Libraries, and then Consolidated Services Claim library. The Consolidated Services Claim List window opens. Double-click to open the desired library. The Consolidated Services Claim Library Maintenance window opens. Select the open menu button . The Consolidated Services Claim Maintenance window opens. Complete the following fields: Effective Date Expiration Date Description Add the Valid Payers Select the Claim Consolidation Rules tab and then select the open menu button and select New. The CSC Timespan Rules window opens. Complete the following fields: In the Length of Timespan field, select Consolidate Monthly Claims. In the Description field, enter a description for this type of billing. In the Rollup Encounter Rate Service Line field, select Yes. In the Encounter Rate SIM Quantity field, select Number of Eligible Days. In the Encounter Rate Service Line Amount field, select Eligible Patient Days times Original Charge Amount. Select OK. Parent topic:

File Maintenance Help for NextGen® Enterprise 8

Set Up for Eligible Number of Patient Days Billing

Access File Maintenance. Select Libraries, and then Consolidated Services Claim library. The Consolidated Services Claim List window opens. Double-click to open the desired library. The Consolidated Services Claim Library Maintenance window opens. Select the open menu button . The Consolidated Services Claim Maintenance window opens. Complete the following fields: Effective Date Expiration Date Description Add the Valid Payers Select the Claim Consolidation Rules tab and then select the open menu button and select New. The CSC Timespan Rules window opens. Complete the following fields: In the Length of Timespan field, select Consolidate Monthly Claims. In the Description field, enter a description for this type of billing. In the Rollup Encounter Rate Service Line field, select Yes. In the Encounter Rate SIM Quantity field, select Number of Eligible Days. In the Encounter Rate Service Line Amount field, select Eligible Patient Days times Original Charge Amount. Select OK. Parent topic:

File Maintenance Help for NextGen® Enterprise 8

Encounter Rate Library with Claim Detail Rules Report

The Encounter Rate Library with Claim Detail Rules report includes information from the Encounter Rate Billing library in File Maintenance. Information on the report pulls from the Encounter Rate Billing Library Maintenance window > Claims tab. The report includes the following information: Column Description Data Populates From Description Library Name Encounter Rate Billing Library field ER Claim Detail Rule ER Claim Detail Rules Description Encounter Rate Claim Detail Rules window > Description field Eff Dt Effective Date Encounter Rate Claim Detail Rules window > Effective Date field Exp Dt Expiration Date Encounter Rate Claim Detail Rules window > Expiration Date field Prim Include Copay Ind Include Copay in Primary Electronic Claim Encounter Rate Claim Detail Rules window > Primary Electronic Claims section (Y/N) Prim ER SIM on the Claim Do you send the ER SIM on the Claim? Encounter Rate Claim Detail Rules window > Primary Electronic Claims section (Y/N) Prim Display narr on ER

Claim Consolidation Rules

Recommendations

Add Claim Consolidation Rules to a CSC Library

Claim Consolidation Rules

Set Up Rules for Consolidation of Case Claims

Set Up for Eligible Number of Patient Days Billing

Set Up for Eligible Number of Patient Days Billing

Encounter Rate Library with Claim Detail Rules Report

Claim Consolidation Rules

Add Claim Consolidation Rules to a CSC Library

Claim Consolidation Rules

Set Up Rules for Consolidation of Case Claims

Set Up for Eligible Number of Patient Days Billing

Set Up for Eligible Number of Patient Days Billing

Encounter Rate Library with Claim Detail Rules Report