Claim Hierarchy to Determine Type of Claim

NextGen® Enterprise PM follows a hierarchy that determines what type of claim form (1500 or UB) is created for each payer. The system moves from the highest to the lowest level in the hierarchy to make the claim determination. It is important to understand the claim hierarchy to properly troubleshoot claim related issues.

Claim Hierarchy (from highest to lowest):

• Payer > Alternate Payer > Location/SIM:

  The first place the system looks in determining the type of claim to be created is the Modify Payer Information window in the Alt Payer tab for the payer attached to the encounter. If the Alt Payer tab is completed for the Location on the encounter, and one or more SIM codes have been defined, then encounters for that location having one or more of the specified SIM codes entered as charges create the type of claim defined on the Alt Payer tab.

• Payer > Practice > UB > Location/Provider:

  The second place the system looks in determining the type of claim to be created is the Modify Payer Information window in the Practice tab then on the UB sub-tab for the payer attached to the encounter. If the UB sub-tab is completed for the Location on the encounter, and the Field Locator 51 field contains a value, and one or more Rendering Providers have been selected, then encounters for that location and provider create a UB claim.

• Service Items Library > SIM Code > Payer > Form:

  The third place the system looks in determining the type of claim to be created is the SIM Library > SIM Code > Payer tab for the payer attached to the encounter. If the Payer tab has a Form defined that is different from the Form on the General tab, then encounters for that payer and SIM code create the specified type of claim.

• Service Items Library > SIM Code > General > Form:

  The last place the system looks in determining the type of claim to be created is the SIM Library > SIM Code > General > Form field.