Examples of Claims with the Claim Level Approved Amount Segment

Help Guide for NextGen® Enterprise PM 8

Examples of Claims with the Claim Level Adjustment Amount Segment

The following examples show the 2320 loop when the claim-level adjustment amount segment is added to institutional and professional claims. The segment is displayed in bold text. 2320 loop for a professional claim with the claim level adjustment amount added The following example shows how the 2320 loop for a professional claim looks with either the Submitter Profile or Payer option set to add the claim level adjustment amounts. Claim level CAS segments are grouped under the adjustment reason group code (e.g. CO, PR, CR, or PI). When the same group code (PR3, PR1) contain specific multiple reason codes, these codes are combined in the same CAS segment. For example, reason codes PR1 and PR3 would be combined in the same CAS segment like this: CAS*PR*3*20**1*100~, with each reason code paired with the corresponding amount. CLM*000100000970*190***11**1*Y*A*Y*O*B******P~ REF*EA*CP1Z3M36NVOA~ HI*BK*25000~ NM1*82*1*TEAM MD*ROBERT*A***24*404803109~ REF*1D*404803109~ SBR*P*18***C1****BL~ CAS*C

Help Guide for NextGen® Enterprise PM 8

Examples of Claims with the Claim Level Approved Amount Segment

The following examples show the 2320 loop when the claim-level approved amount segment is added to institutional and professional claims. The segment is displayed in bold text. 2320 loop for a professional claim with the claim level approved amount added The following example shows how the 2320 loop for a professional claim looks with either the Submitter Profile or Payer option set to add the claim level approved amount. Since there is no distinction between the approved amount and the allowed amount in the claim file, the option to add the claim level approved amount adds both the approved amount (AMT*AAE) and allowed amount (AMT*B6) segments in a professional file. CLM*000100000970*190***11**1*Y*A*Y*O*B******P~ REF*X4*CLIA123~ REF*EA*CP1Z3M3F8R23~ HI*BK*25000~ NM1*82*1*TEAM MD*ROBERT*A***24*404803109~ PRV*PE*ZZ*207QA0505X~ REF*1D*404803109~ SBR*P*18***C1****BL~ AMT*D*138~ AMT*AAE*157~ AMT*B6*157~ DMG*D8*19661013*F~ OI***Y*B**O~ 2320 loop for an institutional claim with the claim lev

Help Guide for NextGen® Enterprise PM 8

Enable Segments for Claim-level Approved Amounts and Adjustments

The Submitter Profile library and the Payer master file both have settings that add the claim-level allowed amount segment and the claim-level adjustment segment to the electronic claim file. Because the settings work independently of each other, you can enable them at either level. However, if the same option is enabled at both levels, the Payer master file setting always overrides the Submitter Profile library setting. The following table shows the various results according to how the submitter profile and payer-level options are set: If the Submitter Profile setting is... And the payer-level setting is set to... Then the segment will... Enabled <none> (blank) Create Enabled Create Disabled Not create Disabled <none> (blank) Not create Enabled Create Disabled Not create Do one of the following: To set the options at the Submitter Profile level: In File Maintenance, select Libraries > Submitter Profiles. Open a submitter profile, and then select the Exception Options tab. Select in th

Help Guide for NextGen® Enterprise PM 8

Examples of Claims with the Claim Level Adjustment Amount Segment

The following examples show the 2320 loop when the claim-level adjustment amount segment is added to institutional and professional claims. The segment is displayed in bold text. 2320 loop for a professional claim with the claim level adjustment amount added The following example shows how the 2320 loop for a professional claim looks with either the Submitter Profile or Payer option set to add the claim level adjustment amounts. Claim level CAS segments are grouped under the adjustment reason group code (e.g. CO, PR, CR, or PI). When the same group code (PR3, PR1) contain specific multiple reason codes, these codes are combined in the same CAS segment. For example, reason codes PR1 and PR3 would be combined in the same CAS segment like this: CAS*PR*3*20**1*100~, with each reason code paired with the corresponding amount. CLM*000100000970*190***11**1*Y*A*Y*O*B******P~ REF*EA*CP1Z3M36NVOA~ HI*BK*25000~ NM1*82*1*TEAM MD*ROBERT*A***24*404803109~ REF*1D*404803109~ SBR*P*18***C1****BL~ CAS*C

Help Guide for NextGen® Enterprise PM 8

Enable Segments for Claim-level Approved Amounts and Adjustments

The Submitter Profile library and the Payer master file both have settings that add the claim-level allowed amount segment and the claim-level adjustment segment to the electronic claim file. Because the settings work independently of each other, you can enable them at either level. However, if the same option is enabled at both levels, the Payer master file setting always overrides the Submitter Profile library setting. The following table shows the various results according to how the submitter profile and payer-level options are set: If the Submitter Profile setting is... And the payer-level setting is set to... Then the segment will... Enabled <none> (blank) Create Enabled Create Disabled Not create Disabled <none> (blank) Not create Enabled Create Disabled Not create Do one of the following: To set the options at the Submitter Profile level: In File Maintenance, select Libraries > Submitter Profiles. Open a submitter profile, and then select the Exception Options tab. Select in th

Help Guide for NextGen® Enterprise PM 8

COB Electronic Claims Sub-Tab

The options on the COB Electronic Claims tab work only for electronic secondary claims and accommodate 837 COB requirements. CAUTION: These options should never be enabled unless the payer requires them. Claim rejections can occur if these segments are present and the payer does not want them. Field Description Populate 2400 CN1 contractual adjustment segment Select this option to add a service line CN1 segment (2400). This amount is also referred to as the OTAF (obligated to accept in full) amount. If this option is enabled and a service line contractual adjustment exists (CAS*CO), then the allowed amount is added as the 2400 CN1 amount. The presence of the CAS*CO segment causes the CN1 segment to create mimicking the allowed/approved amount in the AMT*AAE segment. Enable COB information popup in payment entry Select this option so that during transaction entry the Coordination of Benefits Information window automatically displays when the user tabs out of the Reason field for the las

Examples of Claims with the Claim Level Approved Amount Segment

2320 loop for a professional claim with the claim level approved amount added

2320 loop for an institutional claim with the claim level approved amount added

Recommendations

Examples of Claims with the Claim Level Adjustment Amount Segment

Examples of Claims with the Claim Level Approved Amount Segment

Enable Segments for Claim-level Approved Amounts and Adjustments

Examples of Claims with the Claim Level Adjustment Amount Segment

Enable Segments for Claim-level Approved Amounts and Adjustments

COB Electronic Claims Sub-Tab

Examples of Claims with the Claim Level Approved Amount Segment

2320 loop for a professional claim with the claim level approved amount added

2320 loop for an institutional claim with the claim level approved amount added

Examples of Claims with the Claim Level Adjustment Amount Segment

Examples of Claims with the Claim Level Approved Amount Segment

Enable Segments for Claim-level Approved Amounts and Adjustments

Examples of Claims with the Claim Level Adjustment Amount Segment

Enable Segments for Claim-level Approved Amounts and Adjustments

COB Electronic Claims Sub-Tab