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Generating Secondary Electronic Claims

If you are using electronic remittances, you can generate a secondary electronic claim for COB-specific 837 segments.

Setting the Optional Segments for the 837 Format
Enable Segments for Claim-level Approved Amounts and Adjustments
Display the Family Planning Indicator on All Claims
Run Claim Edits on Appointments or Encounters
Force the Secondary Claim to Bill to the Primary Claim Provider
Exempt Patient Co-Payments
Run the Consolidation Same Day Claims Process
Using Twelve Diagnoses for Electronic Claims
Force Claims to Paper by ICD Code
Setting Up a Release of Information Default

Generating Secondary Electronic Claims

Help Guide for NextGen® Enterprise PM 8

Generating Electronic Secondary Claims from Manually Posted Primary Payments

You can generate HIPAA-compliant electronic secondary claims from manually posted primary payments. A Coordination of Benefits Information window is available from the Payment Entry window for the collection of individual reason codes and adjustment amounts for each detail row on the Payment Entry window. Note: To show all line items on the Payment Entry window, enable the Show All Line Items check box. The amounts from the CPT4 code, billed amount (charge amount), payment amount, allowed amount, and reason codes default from the transaction detail of the Payment Entry window to the Coordination of Benefits Information window. The adjudication date defaults from the Adjudication Date field on the payment batch header (Batch Maintenance window), if the field contains a date. When you select the COB button on the Payment Entry window, the Coordination of Benefits Information window opens. Note: The reason code amount defaults to the Coordination of Benefits Information window if only one

Help Guide for NextGen® Enterprise PM 8

Setting the Optional Segments for the 837 Format

A secondary electronic file adds several new segments to the standard 837 format for primary claims. These segments are added regardless of how the primary payment is posted: Service line payment information (2430 SVD) Service line adjustment information (2430 CAS) Service line adjudication date (2430 DTP*573) Service line approved amount (2400 AMT*AAE) These segments automatically create based on whether the file type is institutional or professional: Claim-level allowed amount (AMT*B6 – institutional only) Claim-level payer amount paid (AMT*C4 – institutional, AMT*D-prof) Claim-level patient paid amount (AMT*F5 –both) Payer requirements dictate if other optional segments can be added. You can enable these optional segments with the electronic secondary claim options in the Payer master file. Parent topic: Generating Secondary Electronic Claims

Help Guide for NextGen® Enterprise PM 8

Coordination of Benefits Electronic and Manual Processing

You can view information on all the payers for EDI claims in the Coordination of Benefits Information (COB) window. The Coordination of Benefits Information window provides information on all payers for EDI claims. This includes primary, secondary, and tertiary payers for 837I, 837P, and 837D claims. A summary of all COB activity by charge lines on an encounter for all previous transactions will display on the Coordination of Benefits Information window. When viewing COB1, COB2, COB 3, or All Payer data fields are editable by transaction line. ERA File When the ERA file contains a CAS segment with a charge line that has two identical reason codes, one CAS segment is created for the two identical reason codes in the 837 file. The reason codes are combined and display on a single line in the 837 file. Example: The COB window contains CO45 $50 and CO45 $25 and a PR2 on a single service line, the CAS segment will create CAS*CO*45*75 in the 837 file to represent the CO45 amounts and continu

File Maintenance Help for NextGen® Enterprise 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

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

Help Guide for NextGen® Enterprise PM 8

837 Electronic File Creation Window

Use the 837 Electronic File Creation window to identify search criteria for claims that you want to send in an electronic file. This window has the following tabs: General, Advanced, and Practices. Each tab contains the File Options and Electronic Claims sections. File Options and Pending Electronic Claims Sections These sections display on each of the tabs for the 837 Electronic File Creation window. File Options - you can select the file for data transfer, identify the batch type, create a report, update claim requests, and send a test file. Pending Electronic Claims - displays the claims that match the search criteria on the active tab. General, Advanced, Practices, File Options, and Pending Electronic Claims Refer to the following topics for information about the fields on this window: 837 Electronic File Creation - General Tab 837 Electronic File Creation - Advanced Tab 837 Electronic File Creation Window Practices Tab 837 Electronic File Creation - File Options and Pending Electr