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The following table describes the options and settings available on the Defaults 2 tab in the Defaults - 2 tab for a payer.
| Field | Description |
|---|---|
| Diag Codes (Diagnosis Codes) | Enter one of the following:
|
| Lab Fac | Enter the laboratory facility. |
| Rad Fac | Enter the radiology facility. |
| Def Accpt Asgn | This is Default Accept Assignment, the default assignment of benefits for the provider. Enter one of the following:
|
| Def Deductible | Enter the default deductible amount that must be met before benefits can be paid. |
| Formulary Provider | Enables you to add a formulary to the payer. |
| Note | Enter additional information, if needed. |
| Cross-over | If this check box is enabled, the payer is identified as a Medicare secondary automatic crossover payer if set up as secondary payer. The payer may also serve as the primary payer. |
| Disable diagnosis claim break |
|
| Dental payer | Enable this check box to designate the payer as a Dental Payer. To bill dental SIMs and create ADA Dental claims, a dental payer must be attached to the encounter.
|
| Require Policy Number | Enable this check box to require a policy number on the Insurance Maintenance window at the patient level. |
| Do Not Sum Units for CPT4 Code | Enable this check box to indicate that for this payer, multiple identical charge lines are prevented from being combined on one line and summed on the paper claim. The identical charges display on separate lines on the paper HCFA 1500 claim or are entered individually in an electronic send file. When the check box is cleared (the application default), the application sums identical line items and indicates multiple units for billing on a paper HCFA 1500 or in an electronic send file. Multiple identical charge lines are prevented from being combined on one line and summed on the paper claim. The identical charges display on separate lines on the paper HCFA 1500 claim or are entered individually in an electronic send file. When the check box is cleared (the application default), the application sums identical line items and indicates multiple units for billing on a paper HCFA 1500 or in an electronic send file.
|
| Require override policy number | Enable this check box to require the override policy number when users add this payer to an encounter for a patient that is not the guarantor. |
| Eligibility\Referral Support | Select this option to use the same payer across all practices in the enterprise for eligibility and referrals rather than selecting the Eligibility Support and Referral Support check boxes in the Other tab of the Practice tab on the Payers master file for each payer. |
| Send Prior Payer ICN on COB Claims | For COB claims, select this check box to:
|
| Display override policy number and co-pay | Select this check box to allow the entry of a patient's co-pay that is different from the insured's co-pay. When this box is selected, the override policy number and co-pay fields for the patient display on the Insurance Maintenance window below the Practice Level section. This allows you to override the co-pay set up at the practice or enterprise level. When a dependent has an encounter created, his or her policy number prints in box 1A of the HCFA 1500 and the subscriber's name prints in box 4. |
| Disable supervisor billing | Select this check box to disable supervisor billing for a specific payer. This setting overrides similar supervisor billing settings at the practice-provider level located in the Practice tab of the Provider master file. |
| Require group number | Select this check box to require a group number on the Insurance Maintenance window at the patient level. |
| Suppress zero balance claims | Select this check box to suppress claims with a $0 (zero) balance during batch biling. |
| Display provider payer Loc ID | Select this check box to display the Loc ID field in the Group Information section of the Practice tab of the Add/Modify Provider window for a specific provider. |
| CPT on Rev Code Roll-up | Select this option to pull the first CPT4 code from the charge for the SIM that is set up as a Revenue Code Rollup in the Payer tab of the SIM Library. This option is used for both electronic (in SV202 in the 837I) and paper (in FL 44 on the UB) claims. |
| Force drug code claim break | Select this option to create a separate claim when charges are found with an associated NDC code. |
| Add tax line item per service line | Select this check box to define that, for this payer, the tax rate will be applied at the line item level. Tax rates are determined by settings in the Tax Rate library. |
| Send ICN on Resubmission | Select this check box to do the following:
|
| Policy Number Format | Select the drop-down arrow to select the required format for entering the policy number on the Insurance Maintenance window. The formats listed in this field are created in the Formats master file.. |
| Group Number Format | Select the drop-down arrow to select the required format for entering the group number on the Insurance Maintenance window. The formats listed in this field are created in the Formats master file. |
| SubGrouping One (User-defined field) | Select one of the payer subgrouping category types that you want to use as a reporting filter for this payer.
|
| SubGrouping Two (User-defined field) | Select one of the payer subgrouping category types that you want to use as a reporting filter for this payer.
|
| Medication Payer Group | Select the Medication Payer Group from the drop-down list to use as the default for your Enterprise. By selecting a Medication Payer Group, you can verify medications at the payer level. The groups listed in this field are created in the Medications by Payer Group master file for NextGen® Enterprise EHR . |
| Default Resubmission Code | Set the default code for the resubmission number to one of the following:
|
| Turn Off Edits | Select this check box to prevent the Edits process from being run when an encounter is being billed to this payer. Use this option carefully because dirty claims could result. |
| Prevent modifying plan name on Insurance Maintenance | Select this check box to prevent the changing of the payer's plan name in the Plan Name field on the Insurance Maintenance window in NextGen® Enterprise PM. |
| Disable sliding fee adjustments when primary | Select this check box to prevent sliding fee adjustments from being taken when the payer is primary.
|
| Populate claim prescription number with claim ID number | Select this option to automatically populate the prescription number for any claim detail records on the claim with the claim ID number. This number is the system-assigned Claim ID. For pharmacy claims this is the value that is subsequently returned back from the payer and so it can be used in ERA. |
| Contracted payer | Select this check box to indicate that the payer is contracted and, therefore, receives different discounts from what a non-contracted payer receives.
|
| Claim charges limit | Enter a number or use the up and down arrows to set the maximum number of charges to send for each claim in the electronic send file. |
| Patient control number digits | Use the up and down arrows to set the number of digits that make up the Patient Control Number. You can also highlight the field and enter the number of digits directly. This feature enables you to match the length of Patient Control Numbers to the requirements of specific payers for claims. |
| Send Diagnosis Mappings on Claims | Specify which diagnoses to send on the claim if the payer cannot accept ICD-10 codes and needs ICD-10 mappings to ICD-9 codes instead of the standard ICD-10 codes. The codes in the mapping options are defined in the Diagnosis Codes library.
Select this check box, and then select one of the following options:
If the check box is not selected, then the standard diagnosis codes stored in charge entry and the encounter diagnosis module will be sent on the claim. |
| Payer Alert | Enter a message that you want to display about the payer. This message can be set to display during the check-in or check-out process in the Alerts Practice Preferences. |