Cost Estimation Data Sources

Service Items (SIM) library	A library that enables you to add SIM codes with associated CPT®4 code for each practice, along with prices. You can also group service items under one main number or name.
SIM exception	A library that enables you to charge different fees according to provider, location, and payer. Additional fees are referred to as exceptions, which can be set up and maintained through the SIM Library.
Contract library	A library that enables you to set up payers for the contract and indicates the reimbursement amount for the procedures.
Contract exception	A library that enables you to charge different fees based on the provider, location, and payer. Each additional fee is referred to as an exception to the contract and can be set up and maintained through the Contract library. After the exceptions are set up, you can assign a contract exception to providers at the provider, payer, or location level to apply the exceptions to charges.
Transaction history	A repository where previous eligibility verification transactions are recorded.
Real time eligibility verification (271) transaction	Electronic response file comprising coverage, eligibility, and benefits information.
Insurance information of the person or patient	Insurance information required for cost estimation is collected and maintained in the Insurance Maintenance window.

Help Guide for NextGen® Enterprise PM 8

Patient Cost Estimation Workflow

The cost estimation feature enables you to use the information within the application to provide an insight into the various costs associated with the different types of care. A practice, running in a real-time system, has a valid NextGen® Eligibility Verification license and is able to communicate with the real-time server. When an eligibility transaction is run, the system receives real-time eligibility (271) transaction file as response. A practice, running in non-real-time system, does not have a valid NextGen® Eligibility Verification license and retrieves values from the local database. If you are the administrator, you must complete the following configurations in File Maintenance. Set up payers in the payer master Set up providers in the provider master Set up the pricing for service item (SIM) codes and associate SIM codes with CPT®4 codes in the SIM library You can configure the following as needed and are not mandatory. Set up sliding fee schedules in the sliding fee schedul

Help Guide for NextGen® Enterprise PM 8

Retrieving Patient Benefits for Cost Estimation

Co-pay, deductible, and coinsurance are collectively referred to as patient benefits. Co-pay is the fixed amount the patient must pay for each visit, which is predetermined in the co-pay clause of the insurance policy. Deductible is the fixed amount a patient must pay each year before the insurance payer begins to cover the costs. After the patient pays the deductible amount as per the insurance plan, the payer starts to share the cost of the service. Coinsurance is the fixed cost for treating the covered services that the patient must bear after the deductible amount is paid. Non-covered charges are incurred on services that do not have insurance coverage. For a practice running in a real-time system, co-pay, deductible, coinsurance, and non-covered charges are retrieved from the real-time eligibility (271) transaction file. For a practice running in a non-real-time system, the patient benefits are retrieved as follows: The co-pay is retrieved from the patient's insurance information,

File Maintenance Help for NextGen® Enterprise 8

Contract Exception Maintenance Filter Criteria and Contract Exception Definitions

Enter the Filter Criteria using the table below. Filter Criteria Action/Required Information Enter the first number(s) of the CPT4 item you want to locate If the CPT4 column contains a lot of items, you can use this field to help you find a CPT4 code. Enter the first few numbers of the CPT4 code until the CPT4 item displays in the spreadsheet area of the window. Include Past CPT4 Items Select this check box to display all expired CPT4 items. Exception CPT4s only Select this check box to display CPT4 exceptions only. Enter the contract exception information for each CPT4 item listed using the table below: Filter Criteria Action/Required Information CPT4 and Date Range These fields display the CPT4 code information from the contract that you selected to create this exception. Allowed Enter the dollar amount allowed by the contract exception for the CPT4 code. Participating % Enter the percentage of the allowed fee that you expect to receive for services rendered by participating provider

File Maintenance Help for NextGen® Enterprise 8

Non-Coordinated SIM Library with Payer Detail Report Columns

The Non-Coordinated SIM Libraries with Payer Detail report includes information from the Non-Coordinated SIM Library in File Maintenance. Information on the report pulls from the Non-Coordinated SIM Maintenance window. The report includes the following information: Column Description Data Populates From Library Name Library Name Non-Coordinated SIM Library Name field Eff Date Effective Date Effective Date field Exp Date Expiration Date Expiration Date field Description Description Description field SIMs List SIMs List Service Item Configurations > Non-Coordinated SIM section Payer List Payer List Service Item Configurations > Valid Payers section Multiple entries are separated by commas. Prior Payer List Prior Payer List Service Item Configurations > Only for Selected Prior Payers section Multiple entries are separated by commas. Provider Credentials List Provider Credentials List Service Item Configurations > Provider Credentialing section Multiple entries are separated by commas. Crt

File Maintenance Help for NextGen® Enterprise 8

Pre-Services Practice Preferences Descriptions

The following table describes the fields located on the pre-services practice preferences. Field Description Patient Payment % The percentage of payment that the patient wants to make in advance. Update patient insurance with copay/deductible information from cost estimation Updates the co-pay and deductible amount in the patient insurance maintenance from cost estimation. Search for Allowed Amount Displays additional information on searching allowed amount. Allowed Amount Source Determines the source location from where the allowed amount can be obtained. You can select one of the following options: Both: The system searches for the allowed amount in the transaction history and contract library. Transaction History: The system searches for the allowed amount in the transaction history for cost estimation. Contract: The system searches for the allowed amount in the contract library for cost estimation. Both is selected by default. Search first by This field is available when Both is se

Help Guide for NextGen® Enterprise PM 8

Insurance Aging Analysis Report Columns

The following columns are available on the Insurance Aging Analysis report: Column Name Description Data Populates From 0-30 0-30 Days Calculated 121-150 121-150 Days Calculated 151-180 151-180 Days Calculated 181-up 181-up Days Calculated 31-60 31-60 Days Calculated 61-90 61-90 Days Calculated 91-120 91-120 Days Calculated Addr1 Address 1 Patient Information Addr2 Address 2 Patient Information Add-On APG Add-On Amount Adj Amt Adjustment Amount Payment Entry Admitting Admitting Provider Encounter Maintenance Aft Care Service Item After Care Days Service Items Library Alt Code Alternate Code Used for billing anesthesia during Charge Posting Charge Posting APG Code APG Code APG Date APG Response Date Bad Debt Bad Debt Balance Amount Patient Chart Base Unit Base Unit Price of Anesthesia This field is used to calculate the price for a SIM when it is designated and used as an anesthesia SIM. Service Items Library Beg Tm Beginning Time Used to calculate anesthesia Charge Posting Blood Quantu

Cost Estimation Data Sources

Recommendations

Patient Cost Estimation Workflow

Retrieving Patient Benefits for Cost Estimation

Contract Exception Maintenance Filter Criteria and Contract Exception Definitions

Non-Coordinated SIM Library with Payer Detail Report Columns

Pre-Services Practice Preferences Descriptions

Insurance Aging Analysis Report Columns

Patient Cost Estimation Workflow

Retrieving Patient Benefits for Cost Estimation

Contract Exception Maintenance Filter Criteria and Contract Exception Definitions

Non-Coordinated SIM Library with Payer Detail Report Columns

Pre-Services Practice Preferences Descriptions

Insurance Aging Analysis Report Columns