Estimate Patient Cost Fields

The following table describe the fields that display patient and guarantor demographic information, list of payers, provider, location, and service type for estimating patient cost on the Estimate Patient Cost window.

Field	Description
	Enables you to select a person or patient record. If you have not selected a person or patient record, a search window opens where you can select the patient or person. If you have already selected a patient or person record, the Modify Patient Information window opens.
	Opens the account, patient chart, or patient balance based on your selection. The menu displays the following options: Account: Opens the patient's account profile. If the selected patient does not have an account, the demographic information opens where you can create the account profile for the selected patient or person. Chart: Opens the chart of the selected patient. If the person does not have a chart, the demographic information opens and you can create a chart for the person. Patient Balance: Opens the patient balance window for the patient. If the selected person is not a patient, the patient balance is not available for selection.
Name	Displays the name of the selected person or patient for whom the cost is estimated.
Address	Displays the address of the selected person or patient.
Date of Birth	Displays the date of birth of the selected person or patient.
Guar Name	Displays the name of the guarantor of the selected person or patient.
Address	Displays the address of the guarantor.
Relation	Displays the relationship of the guarantor with the selected patient or person.
EncNbr and Date	Displays the encounter number and date of the encounter when you estimate patient cost from an encounter.
Appt Date	Displays the date of appointment when you estimate patient cost from an appointment.
Cost Estimate ID	Displays a unique ID (up to 15 characters) for the cost estimate. The system automatically generates a new unique cost estimate ID in the following situations: When you submit a new cost estimation. When you modify the values of an existing cost estimate and submit them. When you submit a cost estimation from an appointment or an encounter. When you submit a cost estimation for a person or patient that has multiple cost estimates.
Clear	Clears and resets the patient or guarantor information.
Payer Selection	Displays a list of payers. You can select only one payer from the list. Note: The payer is displayed in the format: payer name/patient name or person name/relationship with the patient or person. For example, ABC Insurance Company/Patient, Test/Self. The payer list depends on how the cost estimation is initiated. If you open the Estimate Patient Cost window from the toolbar, task menu, an appointment, people or person lookup, or the patient's chart, all the active, available, and unhidden payers are listed. If you open the Estimate Patient Cost window from an encounter, the payers attached to that encounter are listed. If the Estimate Patient Cost window is initiated during autoflow before the encounter insurance selection, all active, available, and unhidden insurances are displayed. If the Estimate Patient Cost window is initiated during autoflow after the encounter insurance selection, the payers attached to that encounter are displayed. The payer can be of different types such as: Payer with contract and without contract exception Payer with contract and contract exception Payer without contract - by posting Electronic Remittance Advise (ERA) or Explanation of Benefits (EOB) When you submit the cost estimation data, the system checks if the payer is associated with the contract or not.
Self Pay	You can select self-pay if the person or patient chooses not to use insurance and plans to pay out of pocket or does not have insurance coverage. When Self-Pay is selected, all services are non-covered by insurance. Note: If you have created self pay payers or self pay contracts and if you want to use a self pay payer added to the payer master or a self pay contract attached to a self pay payer, you can select the applicable self pay payer from the list of payers displayed under Payer Selection.
Provider	Displays the rendering providers involved in the physical examination of the selected person or patient. Note: This field is required. If it is blank, this field appears in red. The system fetches values for the insurance and patient responsibility based on the rendering provider. The rendering providers that appear in Provider depends on how the cost estimation is initiated. If you open the Estimate Patient Cost window from an appointment, the rendering provider selected in the appointment is displayed. If you open the Estimate Patient Cost window from an encounter, the rendering provider selected in the encounter is displayed. If you open the Estimate Patient Cost window from the people or person lookup, Task menu, or the Est Patient Cost icon on the toolbar, the rendering providers associated with the practice are listed in alphabetical order by name. You must select a rendering provider from the list. Note: If your practice is running with NextGen® Eligibility Verification license, you can select the service type in addition to rendering provider and location to get the most accurate patient benefits for copay and deductible.
Location	Displays the service location. The service location that appears in Location depends on how the cost estimation is initiated. Note: This field is required. If it is blank, this field appears in red. The insurance and patient responsibility are calculated based on the service location. Pricing for services can differ from location to location. If you open the Estimate Patient Cost window from an appointment, the service location selected in the appointment is displayed. If you open the Estimate Patient Cost window from an encounter, the service location selected in the encounter is displayed. If you open the Estimate Patient Cost window from the people or person lookup, task menu, or the Est Patient Cost icon on the toolbar, the service locations associated with the practice are listed in alphabetical order. You must select a service location from the list.
Service Type	Displays industry service types. Note: If the practice or provider is licensed for NextGen® Eligibility Verification, patient benefits such as co-pay, deductible, and co-insurance depend on the service type defined for the person or patient. The default service type is Health Benefit Plan Coverage (30).

The following table describes the fields in the Service Items table that enables you to add service line items that must be billed to the person or patient.

Field	Description
Svc Item	Displays the list of Service Item Library codes attached to the SIM Library selected in File Maintenance on the basis of payer and location configuration. To find a specific SIM, type a part of the SIM code. SIM codes that match what you entered are displayed. You can also enter a SIM group to enlist frequently used SIM codes for estimating the cost.
	Located in the Svc Item column, the button enables you to search for a specific service item by SIM code or SIM description.
CPT Code	Displays the CPT® code corresponding to the SIM code that you select in Svc Item. This field cannot be modified. Your system administrator maps every CPT® code to one or more SIM codes.
M1 M2 M3 M4	Determines the modifiers for each service. You can enter up to four modifiers for a service. Each modifier can have one or two alphanumeric characters. If you select a SIM code mapped to a CPT® code with modifiers, the modifiers automatically appear in the appropriate columns.
Description	Displays the description of the CPT® code. This field cannot be modified. You can hover over this field to view the complete description.
Facility	Indicates one of the following: Checked: The service is rendered at a medical facility Cleared: The service is not rendered at a medical facility Pricing varies for services rendered at medical facilities and locations that are not medical facilities.
Unit(s)	Determines the quantity of the service item. The default value is 1 and can be modified.
Charge Amt	Displays the charge amount per unit of the service item as configured in the SIM library. The charge amount for a service item is calculated as follows: [charge amount] = [allowed amount] + [adjustment amount] If a charge amount is not found for the SIM code entered, no value appears in the Charge Amt field.
Allowed Amt	Displays the maximum amount per unit of the service item paid to the provider. The allowed amount includes both insurance and patient responsibility. The allowed amount is fetched from the contract exception, the contract library, or the last historical transaction. Note: If the allowed amount is not found, the system uses the charge amount. Note: When the services are non-covered then the charge amount is taken as the allowed amount for estimation.
Coins	Displays the co-insurance amount, fixed treatment costs for covered services that the patient must bear after paying the deductible amount.
Copay	Displays the co-pay, the fixed dollar amount the patient must pay for each encounter. This amount is predetermined in the co-pay clause of the insurance policy.
Deductible	Displays the deductible, the fixed amount a patient must pay each year before the insurance payer begins to cover the costs. After the patient’s deductible is paid, the payer starts to share the cost of the service. If the deductible is more than the maximum amount that is paid to the provider, the cost estimation calculator considers the maximum deductible amount as the allowed amount.
Adj Amt	Displays the adjustment amount: the portion of the bill that the provider has agreed not to charge. The adjustment amount is the difference between the charge amount and the allowed amount.
Non-Covered	You can select the check box to change the service item to a non-covered charge. Note: For non-covered services, the charge amount is considered as allowed amount for estimation. Note: For a self-pay estimation, all services are indicated as non-covered by default.
Delete	Deletes the selected service line item
Estimation Notes	A free-text field where you can enter in the notes for the cost estimation. The notes will be saved when you submit the data.
ICD-CM	Displays diagnosis codes assigned for the cost estimation. If you open the Estimate Patient Cost window from an encounter, the diagnosis codes assigned to the encounter are displayed by default. You can add or remove diagnosis codes for the cost estimation.
Submit	When you submit the cost estimation data, the system performs the following: Fetches the current date and time for the cost estimation. Generates and displays the unique cost estimation ID. Fetches the charge amount, allowed amount, and adjustment amount. Fetches patient benefits. Evaluates the patient responsibility and insurance responsibility. Saves the estimation notes and diagnosis codes. Saves the cost estimate in the estimation history and in the estimation summary on Chart > Clinical History/Notes.

The following table describes the fields under Estimation Cost that displays the results of the cost estimation.

Field	Description
Copay	Displays the total co-pay amount applied to the service line items in the cost estimation.
Deductible	Displays the total deductible amount applied to the service line items in the cost estimation.
Coinsurance	Displays the total coinsurance amount applied to the service line items in the cost estimation. The system calculates as follows: [coinsurance] = [sum of coinsurance percentage applied for service line items] x [ estimated allowed amount]. If the deductible is less than the estimated allowed amount, [coinsurance]=([estimated allowed] - [deductible]) x ([sum of coinsurance percentage applied for all the covered service line items]) If the deductible is greater than or equal to the estimated allowed amount, then coinsurance is zero
Non-Covered	Displays the total charge amount applied to the non-covered service line items.
Total Pat Est Amt	Displays the total amount that the patient must pay (also called patient responsibility). [patient responsibility] = [copay]+[deductible]+[coinsurance]+[non-covered]
Estimated Charge	Displays the total charge amount applied to the service line items in the cost estimation. [Estimated Charge] = sum of (charge amount per unit * units specified for each service line item)
Estimated Allowed	Displays the total allowed amount applied to the covered service line items in the cost estimation. [Estimated Allowed] = sum of (allowed amount per unit * units specified for each service line item)
Estimated Adjustment	Displays the total adjustment amount applied to the covered service line items in the cost estimation. [Estimated Adjustment] = sum of (adjustment amount per unit * units specified for each service line item)
Patient Resp Amount	Displays the total amount that the patient must pay for the services added in the cost estimation.
Total Ins Est Amt	The total amount that the payer pays for the services used by the person or patient (also called insurance responsibility). [insurance responsibility] = [allowed amount] - [patient responsibility]
Percentage to Request	Displays the percentage of patient responsibility amount that the patient agrees to pay in advance. Note: This value is drawn from Patient Payment% specified in the Pre-Services practice preferences in File Maintenance.
Min Amt to Request	Displays the minimum amount that the patient agrees to pay in advance using the following calculation: [minimum amount to request] = [patient responsibility] x [percentage to request]
Patient Agrees to Pay	The fields under the Patient Agrees to Pay section indicate the payment options for the patient.
Min Amt	You can select the option if the patient wants to pay the minimum advance amount.
Total Pat Est Amt	You can select the option if the patient wants to pay the amount shown in Patient Resp Amount.
Other Amt	If the patient wants to pay a custom amount, you can select the option and enter the amount.

The following table describes the fields in the table under History that displays the previous cost estimations done for the selected person or patient. You can sort the order of the records by selecting the header of any column. By default, the latest estimate is displayed first.

Field	Description
Estimation Date/Time	Displays the date of cost estimation
Cost Estimate ID	Displays a unique ID for cost estimation
Service Date	Displays the date of service rendered
Payer Name/Self Pay	Displays the payer's name or self-pay
CPT(s)	Displays CPT®4 codes (separated by commas) selected for cost estimation
Estimated Charge	Displays the charge amount projected in the cost estimation
Estimated Allowed	Displays the allowed amount projected in the cost estimation
Estimated Patient Amount	Displays the amount projected as patient responsibility in the cost estimation
Patient Agrees to Pay	Displays the amount that the patient or person agrees to pay in advance
Patient Paid Amount	Displays the amount paid by the patient
Created By	Displays the name of the staff member who has created the cost estimation

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