Eligibility Requests

Help Guide for NextGen® Enterprise PM 8

Eligibility Responses

The following sections explain the NextGen® Eligibility Verification Response received from the payer. The user interface for Real-Time Eligibility Response is informative and easy to navigate. Color codes and symbols make the data easy to understand and to confirm successful responses like Active, Inactive, and Limited. When a payer returns a Limited response, the message is advising providers to contact the payer with further verification. An example is an eligibility response record with a type 'V' (Cannot Process) is handled like type 'U' (Contact for Verification). You can view the latest successful eligibility response from the payer irrespective of having a pending status transaction for the specified time period (in days) as per user preference . To specify the number of days in the user preferences, go to NextGen Healthcare Success Community and download the latest Layout and User Preferences Guide for NextGen Enterprise PM, and refer to the Set General Preferences section. Yo

Help Guide for NextGen® Enterprise PM 8

Submit Eligibility Requests

There are several ways to submit eligibility inquiries: NextGen® Eligibility Verification Submission NextGen® Eligibility Verification Batch Submission Scheduled Batch through NextGen® Background Business Processor NextGen® Eligibility Verification transactions are submitted from different NextGen® Enterprise PM access points. The access points are Patient Lookup Appointment Book Appointment List Encounter Lookup From any of these access points, a NextGen® Eligibility Verification request can be submitted for a single patient by right-clicking on the patient, appointment, or encounter, and then selecting Eligibility Verification. Regardless of the access point, the user interface is the same. Several inquiries can be submitted at one time using batch mode. Manually submitting a batch of eligibility inquiries can be done from the appointment lookup and encounter lookup. This manual batch was referred to as Real Time batch. (Long time RTS users also know this as pseudo-batch.) Finally, b

Help Guide for NextGen® Enterprise PM 8

Submit Eligibility in Batch Mode Using Background Business Processor

Before you can run eligibility inquiries in batch mode, the eligibility profiles library must be defined. This library enables you to set up rules to automatically complete the required fields and additional data in batch mode that you would manually enter in NextGen® Eligibility Verification in real time. These libraries are set up during implementation by your administrator with the help of an analyst. Prior to submitting eligibility inquiries in batch mode using NextGen® Background Business Processor, two jobs must be created: NextGen® Eligibility Verification request and NextGen® Eligibility Verification response. The request job queries the appointments and submits the data to NextGen for processing while your response job later takes the results from the NextGen server and delivers the response to your database. For information on creating a job in NextGen® Background Business Processor for eligibility requests and responses, go to NextGen Healthcare Success Community and downloa

Help Guide for NextGen® Enterprise PM 8

Eligibility for Unattached Payers

Eligibility inquiries can be submitted for a payer without first attaching it to a patient’s chart. In the case of Medicare or Medicaid replacements, this process can occur multiple times per patient. This feature enables you to submit NextGen® Eligibility Verification for a payer that is not attached to a patient’s chart. If active coverage is obtained, then the payer can be attached to the patient with a single selection. This feature is optional and enabled in Practice Preferences. Enable Eligibility Preferences in Practice Preferences You must enable eligibility submission for unattached payers in Practice Preferences to be able to submit eligibility inquiries. Submit Eligibility for an Unattached Payer You can submit eligibility inquiries for a payer that is not attached to a patient's chart. Parent topic: Eligibility Requests

Help Guide for NextGen® Enterprise PM 8

About Eligibility Verification

NextGen® Eligibility Verification is an electronic method of verifying a patient's eligibility and benefit coverage online. EV allows you to check for authorization and prior authorization, make a referral request, check referral history, and check a claim status. The rules governing eligibility and referrals are based on a patient's managed care coverage plan. The following are NextGen® Eligibility Verification features: Eligibility verification enables you to verify a patient's insurance coverage in real-time or in a batch using Background Business Processor. The results of the verification can flow directly into the patient's chart. Referral requests are made to generate a referral number, so that a primary care physician (PCP) can send a patient to an authorized specialist. Referral history enables you to view a patient's referral history. This history lists all previous referrals made for a patient. Claim status check enables you to find out the status of a claim and where it is i

Help Guide for NextGen® Enterprise PM 8

Submit Eligibility From Appointment Scheduling

When enabled from File Maintenance, the NextGen® Eligibility Verification appears when users create an appointment and the following conditions are met: The user has security rights to submit eligibility inquiries. The patient has at least one eligibility-enabled payer attached. The appointment creation date is within the number of days specified in Practice Preferences. An NextGen® Eligibility Verification for the first payer listed for the patient, that is eligibility-enabled, has not successfully processed an inquiry within the time-frame specified in the payer’s Eligibility Profile Library. Event chosen on appointment is selected in Practice Preferences to submit eligibility during appointment scheduling. The standard NextGen® Eligibility Verification window appears when all conditions are met. Parent topic: Eligibility Requests

Eligibility Requests

Recommendations

Eligibility Responses

Submit Eligibility Requests

Submit Eligibility in Batch Mode Using Background Business Processor

Eligibility for Unattached Payers

About Eligibility Verification

Submit Eligibility From Appointment Scheduling

Eligibility Responses

Submit Eligibility Requests

Submit Eligibility in Batch Mode Using Background Business Processor

Eligibility for Unattached Payers

About Eligibility Verification

Submit Eligibility From Appointment Scheduling