Encounter Rate Billing

Help Guide for NextGen® Enterprise PM 8

Charge and Billing Options for Health Centers

In most cases, the special setup for Health Centers applies only to Medicare and Medicaid. This includes Managed Care programs for Medicare and Medicaid which are often considered to be commercial payers. Blue Cross Blue Shield and Commercial payers typically bill as Fee-for-Service on a 1500 claim form just like at other private practices. No special setup is required for these payers. However, every state has potential for exceptions. Therefore, any payer can be setup for encounter rate or roll-up billing if needed. Encounter Rate Billing: This is an option for payers such as Medicare (FQHC / RHC) and Medicaid that have unique and specific billing and claim requirements, and that reimburse at a flat encounter rate. Encounter Rate Billing provides the ability to automatically adjust charges so that the balance reflects the payer’s expected encounter reimbursement rate/amount. In addition, an encounter rate code required by the payer on claims can be automatically inserted onto each en

Help Guide for NextGen® Enterprise PM 8

Roll-Up Billing

Roll-Up Billing is an option for payers such as Medicare (RHC only) and Medicaid that have very unique and specific billing and claim requirements, and that reimburse at a flat encounter rate. Roll-Up Billing provides the ability to roll-up multiple charges on an encounter into a single line item on the claim. The amount on that line item will equal the total sum of the rolled-up charges. The roll-up can be done by revenue code (for example, 0521) or by CPT4 Code (for example, T1015). Note: Best practice is to use Encounter Rate Billing for both Medicare and Medicaid. In some cases, roll-up billing will not meet the billing and claim requirements for a payer (e.g. FQHC Medicare). Before proceeding with the setup for roll-up billing, always consult with a NextGen Healthcare Implementation Specialist and a Claims Analyst to confirm that this is the best setup option to meet the payer's specific billing requirements. The roll-up billing considerations are as follows: Claims are not config

Help Guide for NextGen® Enterprise PM 8

Process Date for Encounter Rate SIM and Adjustments

Some payers, such as Medicare for a Federally Qualified Health Center (FQHC), require that an encounter rate SIM code, or payment code, be included on claims to describe the type of visit. For example, code G0466 on a Medicare claim indicates a new patient visit, and code G0467 indicates an established patient visit. The Encounter Rate Billing library in File Maintenance can be setup for a payer to automatically insert the ER SIM code, or payment code as an additional charge line on encounters during the billing process in NextGen® Enterprise PM. With this setup, there is the potential for an ER SIM charge inserted by the system to have a process date that is different from the process dates on the original charge lines. For example, the original charges on an encounter may have been entered and processed on 2/28/17, but the encounter was not billed until 3/2/17. In this scenario, the original charges have a process date in the February accounting period, and the ER SIM charge on the s

Help Guide for NextGen® Enterprise PM 8

Setting Up Encounter Rate Billing

Encounter rate billing in NextGen® Enterprise PM involves the following setup in System Administrator and File Maintenance: Security Access Rights Enterprise Preferences Practice Preferences CPT4 Codes Revenue Codes Departments Service Items Library Claim Edits Library Transaction Codes Encounter Rate Billing Library Payers Set Up Security Access Rights for Encounter Rate Billing Set Up Enterprise Preferences for Encounter Rate Billing Practice Preferences for Encounter Rate Billing Add or Modify CPT4 Codes for Encounter Rate Billing Add or Modify Revenue Codes for Encounter Rate Billing Add or Modify Departments for Encounter Rate Billing Add or Modify SIM Codes for Encounter Rate Billing Set Up Claim Edits for Encounter Rate Billing Add or Modify Transaction Codes for Encounter Rate Billing Add or Modify an Encounter Rate Billing Library Set Up Payers for Encounter Rate Billing Parent topic: Encounter Rate Billing

Help Guide for NextGen® Enterprise PM 8

Set Up Payers for Encounter Rate Billing

Once the Encounter Rate Billing library has been created, it must be attached to the appropriate encounter rate payers. Attaching the Encounter Rate Billing library ensures that during the billing process in NextGen® Enterprise PM, the ER SIM code is inserted onto the encounter and the claim is configured correctly to meet the ER payer's specific requirements. Access File Maintenance. Select System Master Files, then PM, and then Payers. The Payers List window opens. From the list, select an ER payer, and then select Open Menu and select Open. The Modify Payer Information window opens. Select the Practice tab, and then select the Libraries sub-tab. In the Encounter Rate Library field, select the Encounter Rate Billing library for the payer. Modify Payer Information To save changes and close the window, select OK. Parent topic: Setting Up Encounter Rate Billing

Help Guide for NextGen® Enterprise PM 8

Enable Qualifying Encounter Billing

The Encounter Rate Billing functionality in NextGen® Enterprise PM includes logic that identifies multiple encounters for a patient on the same date of service at the same location with the same encounter rate payer. Qualifying Encounter Billing must be enabled for the practice. When enabled, the Encounter Rate Billing Status fields display on the Billing & Collections tab of the Encounter Maintenance window. These fields are used to determine which encounter to bill when a patient has multiple same-day encounters with more than one provider at the same location with the same encounter rate payer attached. Access NextGen® Enterprise PM. From the Admin menu, select Preferences, and then Practice. The Practice Preferences window opens. From the Preference List, select Claims. Select the Enable Qualifying Encounter Billing check box. To save changes and close the window, select OK. Parent topic: Practice Preferences for Encounter Rate Billing

Encounter Rate Billing

Recommendations

Charge and Billing Options for Health Centers

Roll-Up Billing

Process Date for Encounter Rate SIM and Adjustments

Setting Up Encounter Rate Billing

Set Up Payers for Encounter Rate Billing

Enable Qualifying Encounter Billing

Charge and Billing Options for Health Centers

Roll-Up Billing

Process Date for Encounter Rate SIM and Adjustments

Setting Up Encounter Rate Billing

Set Up Payers for Encounter Rate Billing

Enable Qualifying Encounter Billing