Determining Crossover Claims

Help Guide for NextGen® Enterprise PM 8

Reading the ERA Import Posting Report

After you have completed the ERA Posting process, the ERA Import Posting report generates. Overall, the report is a complete audit of the ERA 835 file and is grouped by unsuccessful and successful entries. NextGen® Enterprise PM does not, however, report provider level adjustments. The report is sorted by practice with the ERA payments that did not post successfully listed first, followed by all the ERA payments that posted successfully. An ERA message displays in the Description column of the report next to each line item as an indicator for why the ERA claim payment did or did not post against the encounter information. Each of these messages applies to ANSI file formats. The transaction level Reason Codes that are distributed to service lines display on the report, along with their descriptions. Note: The ERA Import Posting report detects and rejects an ERA transaction with a denial reason code and total transaction amount that is not $0.00. Resolving Encounter-Related ERA Errors On

Help Guide for NextGen® Enterprise PM 8

5010 Compliance

The ERA recognizes 5010 compliant claim status codes. It matches on payer based upon the hierarchy of Payer Nbr, Policy nbr, and Claims Status. When the claim status equals 4, the application reads the version number of the 835 and determines if it is a 5010 claim. It then automatically posts the transactions with an Appeal / Skip ERA Adjustment status. The ERA Import Posting report displays the following message: "Line Item Successfully Posted - Patient/Subscriber is not recognized by the Ins". If "Never" is selected in the Remittance Profile Library, the 0.00 payment is not posted. In this case, the ERA Import Posting displays the following message: "Not Posted - Patient/Subscriber is not recognized by the Insurance". When Claim Status does not match the correct COB, the application: Does not post payments when Claim Status Indicator does not match the correct bucket. The ERA Import Posting report displays the following message: "Payment not posted due to Claim Status Indicator not m

Help Guide for NextGen® Enterprise PM 8

Posting an Electronic Remittance

This section provides information about the process of posting an electronic remittance. When posting the ERA, the system compares the ERA payment information for each claim in the file against the encounter information in your system that the claim was originally created for. In order for the ERA payments for each claim to post successfully, the ERA payment information for a claim must match the encounter information the ERA is posting against. If there is a discrepancy between the ERA information and the encounter information, the ERA payment for that claim does not post and an error message displays on the ERA Import Posting report. In addition, if an ERA payment is posting against multiple line items in an encounter, all the line items must be error-free for the ERA payment to post successfully. The ERA process only calculates and posts adjustments for encounter primary and secondary payers. If the primary ERA pays a charge off, it is settled to the secondary and is included on the

Help Guide for NextGen® Enterprise PM 8

Additional Information

If a patient has a payer with the ERA – Create Zero Dollar Total Balance Claims to Selected Subsequent Payer(s) check box enabled, whether the payer is primary or secondary, and the patient’s next payer is one of the selected subsequent payers, then when an ERA 835 file is processed for that payer and an adjustment is posted from the CAS segment, the following occurs: Transaction Detail Status for charge line items associated with the claim default to Settled move to subsequent payer. Charge line items associated with the claim are flagged for rebill. The encounter status changes from Billed to Rebill. When the ERA – Create Zero Dollar Total Balance Claims to Selected Subsequent Payer(s) check box is not enabled for the payer and an adjustment reason code is defined with a Transaction Detail Status of Settled moved to secondary or Settled moved to tertiary, the following occurs when an ERA 835 file with that adjustment reason code is processed: Transaction Detail Status for charge line

Help Guide for NextGen® Enterprise PM 8

Resolving Internal System-Related ERA Errors

The ERA messages outlined here are related to internal system errors. These ERA messages are also considered primary and secondary. The primary error ERA message This type of ERA message indicates the exact line item in the encounter that caused the ERA posting process for the encounter to be unsuccessful. The secondary ERA message This type of message displays for any line item following the primary error. Because the ERA posting process was stopped due to the primary error, these line items are not processed. The following table outlines each of the primary error ERA messages and the associated secondary ERA messages, a description of why the primary and secondary ERA message may have occurred, and the possible resolution to the primary error message. Primary Error ERA Message Message Description How to Resolve Insurance not found for this encounter. The ERA file information for the insurance associated with this encounter does not match the insurance associated with the encounter in

Help Guide for NextGen® Enterprise PM 8

Default Settings in Remittance Profile

The following table describes the settings for the Default tab in Remittance Profile. Option Description Encounter Payer Matching (After GS02 Payer Nbr) Use the following Encounter Payer Matching option To identify the payer during ERA matching, you can select one of the following options: Select Payer using Claim Status (Default): After identifying the payer using the GS02 and the ERA payer number, match will further include the CLP02 claim status returned in the 835 file. The following are the most common claim statuses. 1 = Primary Payer 2 = Secondary Payer 3 = Tertiary Payer 19 = Forwarded 22 = Reversal Select Payer using Claim Status with Policy NumberAfter identifying the payer using the GS02 and the ERA payer ID, it will also match the claim status and the policy number returned in the 835 file. The ERA matches the Encounter Payer's policy number using the claim status. An ineligible policy number is produced when matching fails on both policy number and claim status. Selecting

Determining Crossover Claims

Recommendations

Reading the ERA Import Posting Report

5010 Compliance

Posting an Electronic Remittance

Additional Information

Resolving Internal System-Related ERA Errors

Default Settings in Remittance Profile

Reading the ERA Import Posting Report

5010 Compliance

Posting an Electronic Remittance

Additional Information

Resolving Internal System-Related ERA Errors

Default Settings in Remittance Profile