The cost estimation feature enables you to use the information within the application to provide an insight into the various costs associated with the different types of care.
A practice, running in a real-time system, has a valid NextGen® Eligibility Verification license and is able to communicate with the real-time server. When an eligibility transaction is run, the system receives real-time eligibility (271) transaction file as response.
A practice, running in non-real-time system, does not have a valid NextGen® Eligibility Verification license and retrieves values from the local database.
If you are the administrator, you must complete the following configurations in File Maintenance.
- Set up payers in the payer master
- Set up providers in the provider master
- Set up the pricing for service item (SIM) codes and associate SIM codes with CPT®4 codes in the SIM library
You can configure the following as needed and are not mandatory.
- Set up sliding fee schedules in the sliding fee schedules master
- Set up the contract for payers to indicate the reimbursement amount for the procedures. You can configure the following in the contract library.
- Contract defaults
- Modifier reimbursement
- Multiple procedure discount
- Contract exception
- Set up contract library and contract exception to retrieve the coinsurance and co-pay amount. You can configure the following:
- Contract for the payer
- Participating provider
- Fee schedule for CPT®4 codes
- Set up cost estimation form template for printing
- Set up pre-services practice preferences
- Set up sliding fee preferences in practice preferences to apply the sliding fee adjustment on an estimation
- Add cost estimation in the autoflow sequence
For more information on the configurations in File Maintenance, go to
NextGen Healthcare Success Community and download the following documents.
- File Maintenance Libraries Guide forNextGen®Enterprise
- File Maintenance Master Files Guide forNextGen®Enterprise
- File Maintenance Preferences Guide forNextGen®Enterprise
If you are a front-office staff, the insurance or referral coordinator, or the office manager, you can use the following workflow to estimate the patient cost.
- Log on to NextGen® Enterprise PM.
- Open the Estimate Patient Cost window.
- Select a person or patient who needs the cost estimate.
- Select a payer or self-pay.
- Select the provider, location, and service type.
- Enter the SIM codes, estimation notes, and assign diagnosis codes.
- Submit your selections for cost estimation.
When you submit the data for cost estimation, the system evaluates and displays the patient responsibility and insurance responsibility.
You can print the cost estimation. When the patient wants to pay, you can initiate the payment process from the cost estimate.
You can view the previous cost estimation results from the history of cost estimations and the chart (clinical history/notes) of the patient.
