Claims
A claim is a request by the insurance holder to their insurance company for payment towards services rendered in a practice for the patient.
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Help Guide for NextGen® Enterprise PM 8
Billing is the process where claims are submitted by a practice to an isurance company for the services rendered. A statement is a medical bill that lists all the treatments undergone by a patient in a practice. Electronic Remittance Adive (ERA) is an electronic communication that explain in detail the EOB (Explanation of Benefits) for a particular service. This section discusses in detail about the billing process, statements, insurances, and claims. Billing Statements A statement is generated for all accounts where the guarantor has an outstanding unpaid Balance. Claims Electronic Remittance Advice You can set up and process HIPAA ASC X12N 835 Electronic Remittance Advice (ERA) transaction files in NextGen® Enterprise PM.Billing, Statements, Claims, and ERA
Help Guide for NextGen® Enterprise PM 8
Claims can be processed on demand or in batch mode. This section explains: Paper claims Electronic claims - 837 files 997 files 277 files ERA - 835 files COB - manual posting Processing Paper Claims Claim Production Status Report Processing Electronic Claims - 837 Files Process Claim Requests for Multiple Encounters 997/999 File 277 File Coordination of Benefits Electronic and Manual Processing You can view information on all the payers for EDI claims in the Coordination of Benefits Information window. Parent topic: ClaimsClaims Processing
Help Guide for NextGen® Enterprise PM 8
This section explains generating and submitting claims in general and under certain conditions. Search for Claim Requests You can search a claim request by the claim's status, type, physician, and service location, or by the first or last name of the patient through the Claim Request Lookup window. Generate Paper Claims Preview and Print Paper Claims You can bulk preview and print paper claims. Open the Waystar Website from Claims Lookup You can open the Waystar website through the claims lookup to submit a claim. Generating Courtesy Claims Parent topic: ClaimsGenerating and Submitting Claims
Help Guide for NextGen® Enterprise PM 8
This section explains the process of creating a Consolidated Services Claim (CSC). This process enables you to consolidate claims when a patient has more than two encounters and the same payers are attached for billing. Claims can be consolidated by a single date, week, calendar month, or case. This section covers the following topics: CSC Terms Rules for Claims Consolidation Automatic Identification of CSC Candidate Encounters Consolidate Claims by Time Span Create HOLD Claims for CSC Candidate Encounters Set Up CSC Options for an Encounter Create a Consolidated Services Claim Rebill a Consolidated Services Claim Significant Events for Consolidated Claims Create a CSC Event Audit Trail Claim Production Status report for CSC Candidate Encounters Create Tasks from the Consolidated Services Claim report EDI Format of CSC Claims CSC Terms Rules for Claims Consolidation in a Hold Status Rules for CSC Claims - Condition, Value and Occurrence Codes Admission Date and Time Rules for ConsolidaConsolidated Service Claims
Help Guide for NextGen® Enterprise PM 8
The Claim Request Lookup window enables you to search through the system for claims that match the search criteria. In NextGen® Enterprise PM, select Tasks > Lookup > Claims or select the Claims icon. The Claim Request Lookup window opens. To search for claims by request status, media type, claim type, or rendering physician, use the General tab. To search for claims by supervising physician, claim number, or acknowledgment status, select the Advanced tab. Select Find. The search results appear in the Claim Requests list. Double-click the claim in the Claim Requests list to access a claim request. Note: There is a green check mark in the Consolidated Service Claims (CSC) column for all the CSC candidate claims. CSC cannot be deleted. General Search Criteria You can search a claim by its status, media type, claim type, or rendering physician through the General tab of the Claim Request Lookup window. Advanced Search Criteria Parent topic: Generating and Submitting ClaimsSearch for Claim Requests
Help Guide for NextGen® Enterprise PM 8
When a claim is created from the billing/claim edits process, it has a status of Pending. Once the pending claim is processed by being printed (paper) or added to an EDI file (electronic), the claim status changes to Archived. Archived claims have a Process Date that indicates the date the claim was put into an archived status. Access an Archived Claim Access an Archived Claim from the Encounter Claim Request Window Parent topic: UB Claims