Fields in the Claims Tab of Encounter Maintenance
The General sub-tab under Claims tab includes information about the patient’s encounter that may be needed on an electronic or paper claim for the encounter.
The Claims tab includes three sub-tabs:
- General
- Attachments
- Consolidated Services Claim
The tab includes the following fields:
| Field | Description |
|---|---|
| Special Program | Select the Special Program to which the encounter is related, if applicable. The selected program will include a corresponding indicator in the 2300 loop / CLM012 segment on an electronic claim for the encounter. Available options include:
|
| Serv Auth Except Code | Select the Service Authorization Exception Code as a reason an authorization was not obtained for the encounter, if applicable. The selected code will include a corresponding indicator on an electronic claim for the encounter. Available options include:
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| EPSDT Referral Condition Code | Select the EPSDT (Early Periodic Screening Diagnosis and Treatment) program Referral Condition Code for the encounter, if applicable. The selected code will include a corresponding indicator in the 2300 loop / CRC segment on an electronic claim for the encounter. Available options include:
|
| EPSDT Referral Code | Select the EPSDT (Early Periodic Screening Diagnosis and Treatment) program Referral Code for the encounter, if applicable. The selected code will include a corresponding indicator in the 2300 loop / NTE segment on an electronic claim for the encounter. Available options include:
|
| EPSDT Encounter Code - Paper | Select the EPSDT (Early Periodic Screening Diagnosis and Treatment) program Encounter Code for the encounter, if applicable. The selected code will include a corresponding indicator in Box #24H on a paper 1500 claim for the encounter. Available options include:
|
| Date Last SRP | Displays the date when SRP was last done. The user has to manually enter the date. |
| Condition Code Category - WC | Select one of the following Condition Code Categories to be included on claims for a work comp encounter, if applicable:
|
| Demonstration Project ID | When this field is populated and the encounter is billed, and a claim is created, the Demonstration Project Identifier is populated in Claims Maintenance > Claim Header record in the Demonstration Project ID field on the pending claim for both 1500 (837 Professional) and UB (837 Institutional) claims. |
| Hearing/Vision Rx | If required by the payer, select the date a prescription was written for a hearing device or vision frames/lenses. The date will be included in the 2300 loop / DTP*471 segment on an electronic claim for the encounter. |
| Claim Codes | Enter a free-text claim code for the encounter, if applicable. |
| Vision Code Category | If required by the payer, select the Vision Code Category for replacement frames/lenses when this information impacts reimbursement. The category will be included in the 2300 loop / CRC segment on an electronic claim for the encounter. Available options include:
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| Vision Condition Indicator | If required by the payer, select the Vision Condition Indicator for replacement frames/lenses when this information impacts reimbursement. The indicator will be included in the 2300 loop / CRC segment on an electronic claim for the encounter. Available options include:
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| FQHC Qualifying Encounter | Select this check box to indicate the encounter is considered a face-to-face encounter with a qualified provider and should be flagged as a "qualifying encounter" for Health Center reporting purposes. If the encounter has a charge for a SIM code that is flagged as a "Qualifying Encounter" code in the Service Items Library, then this check box is automatically selected by the system when the encounter goes through the billing process in NextGen® Enterprise PM. |
| Not assigned provider sending electronic claim | Select this check box to include an indicator on electronic claims that the rendering provider is not assigned with the payer. |
| Family Planning Encounter | Select this check-box to indicate the encounter is related to Family Planning. If selected, this places a Y into the detail-level Family Planning flag during billing. The electronic send file then contains a Y in the SV112 segment. |