Configuring Business Rules for Denial Management

Help Guide for NextGen® Enterprise PM 8

2100 Claim Level Reason Codes

This section provides additional information on Claim Level reason codes that are returned in the ERA 835 file at the 2100 Claim Level. Settings in the Remittance Profiles Library and the Reason Codes Library work together to determine how these claim level codes are handled when the ERA file is imported and processed in NextGen® Enterprise PM. For example, when a denial code is returned at the 2100 claim level, it may be desirable to post the transaction to line items on the encounter with a status of Appeal so charge balances remain in the current payer bucket in Balance Control without moving to the subsequent payer or patient bucket. In the image below, code CO20 is setup in the Reason Codes library as a Claim Level code with a Transaction Detail Status of Appeal. The Apply Trans Detail Status (per claim) setting in the Remittance Profiles library determines which line items the Transaction Detail Status is applied to. <none>: Transaction detail status for claim level reason codes

Help Guide for NextGen® Enterprise PM 8

Select Transaction Status for Default Option

When you select any of the default options that are available in the Reason Code Library Maintenance window, and you want to ensure that the remaining balance of respective transactions remains in the same payer bucket to follow up with the primary payer, you must select Transaction Status option as applicable. In File Maintenance, select Libraries > Reason Codes. The Reason Codes List window opens. Select the required reason code from the list and right-click to open or select open menu and select New for new reason code. The Reason Code Library Maintenance window opens. Select the required default reason code check box: Default for Contract <> Payment Allowed Amount Default for Contract <> ERA Payment Amount Default for ERA Credit Balance Creation Select any one of the following option in the Transaction Status field. This will ensure that the remaining balance of respective transactions will remain in the same payer bucket. None Deny Appeal Settled moved to primary Note: If you do n

Help Guide for NextGen® Enterprise PM 8

Reason Code Options

The following table lists each option available in the Reason Codes Library with a description of how it works and how it may be used. Reason Code Option How it Works How it is Used Force Item Rebill Select this check box to flag line items with the reason code to "Rebill" to the current payer. Note: This option applies to Line Item reason codes only. When trends are identified for a reason code that always require rebilling. Write Off Remaining Balance Select this check box to adjust the remaining balance to $0.00 for line items with the reason code. The adjustment occurs when the transaction batch is posted. Note: This option applies to Line Item reason codes only. Sometimes used with payers of last resort, such as Medicaid. Note: ERA uses the Adjustment Code selected below to make the adjustment. Manual payment entry uses the Write Off Remaining Payer Balance adjustment code selected in Practice Preferences > Transactions to make the adjustment. Display on Patient Statements Select

Help Guide for NextGen® Enterprise PM 8

Configuring Business Rules for Denial Management

With the implementation of ERA, it is necessary to create a set of business rules that will direct NextGen® Enterprise PM on how to handle adjudicated claims, particularly denials. These adjustments and denials are identified by the payers with HIPAA standard reason codes. In NextGen® Enterprise PM, ERA adjustments are automatically posted for reason codes pre-fixed with CO (contractual obligation), OA (other adjustment) and PI (payer initiated). Adjustments are not taken for reason codes pre-fixed with PR (patient responsibility). NextGen® Enterprise PM also moves the remaining balance to the next responsible payer automatically when an ERA transaction is posted; from COB1 to COB2 (if a secondary payer exists), from COB2 to COB3 (if a tertiary payer exists), and finally to patient responsibility. In order to fully automate the ERA Posting process, certain selections must be made in the Reason Codes Library to ensure that only the appropriate reason codes are taking adjustments and tha

Help Guide for NextGen® Enterprise PM 8

Setting Up Reason Codes for ERA

Reason codes are used by payers within the ERA 835 file to describe how the services are adjudicated. Payers are required to use HIPAA compliant codes in the ERA file that include a “Group” pre-fix, along with the actual code. (e.g. CO45) Group Codes: CO – Contractual Obligation PR – Patient Responsibility OA – Other Adjustment PI – Payer Initiated The HIPAA X12 Standard Reason Codes library in File Maintenance is pre-installed in the application and contains the industry standard Reason Codes. Important: The HIPAA X12 Standard Reason Codes library should never be hidden or renamed. The COB functionality in NextGen® Enterprise PM that is used for electronic secondary/tertiary claims, references the HIPAA X12 Standard Reason Codes library. It is important to remember that only HIPAA standard codes can be transmitted electronically for secondary/tertiary claims. Practice Level vs. Payer Level Libraries A Default Reason Code Library must be selected in Practice Preferences > Transactions.

Help Guide for NextGen® Enterprise PM 8

Setting Up Reason Codes for ERA

Reason codes are used by payers within the ERA 835 file to describe how the services are adjudicated. Payers are required to use HIPAA compliant codes in the ERA file that include a “Group” pre-fix, along with the actual code. (e.g. CO45) Group Codes: CO – Contractual Obligation PR – Patient Responsibility OA – Other Adjustment PI – Payer Initiated The HIPAA X12 Standard Reason Codes library in File Maintenance is pre-installed in the application and contains the industry standard Reason Codes. Important: The HIPAA X12 Standard Reason Codes library should never be hidden or renamed. The COB functionality in NextGen® Enterprise PM that is used for electronic secondary/tertiary claims, references the HIPAA X12 Standard Reason Codes library. It is important to remember that only HIPAA standard codes can be transmitted electronically for secondary/tertiary claims. Practice Level vs. Payer Level Libraries A Default Reason Code Library must be selected in Practice Preferences > Transactions.

Configuring Business Rules for Denial Management

Recommendations

2100 Claim Level Reason Codes

Select Transaction Status for Default Option

Reason Code Options

Configuring Business Rules for Denial Management

Setting Up Reason Codes for ERA

Setting Up Reason Codes for ERA

Configuring Business Rules for Denial Management

2100 Claim Level Reason Codes

Select Transaction Status for Default Option

Reason Code Options

Configuring Business Rules for Denial Management

Setting Up Reason Codes for ERA

Setting Up Reason Codes for ERA