Reason Code Types

Help Guide for NextGen® Enterprise PM 8

Reason Code Options

The following table lists each option available in the Reason Codes Library with a description of how it works and how it may be used. Reason Code Option How it Works How it is Used Force Item Rebill Select this check box to flag line items with the reason code to "Rebill" to the current payer. Note: This option applies to Line Item reason codes only. When trends are identified for a reason code that always require rebilling. Write Off Remaining Balance Select this check box to adjust the remaining balance to $0.00 for line items with the reason code. The adjustment occurs when the transaction batch is posted. Note: This option applies to Line Item reason codes only. Sometimes used with payers of last resort, such as Medicaid. Note: ERA uses the Adjustment Code selected below to make the adjustment. Manual payment entry uses the Write Off Remaining Payer Balance adjustment code selected in Practice Preferences > Transactions to make the adjustment. Display on Patient Statements Select

Help Guide for NextGen® Enterprise PM 8

2100 Claim Level Reason Codes

This section provides additional information on Claim Level reason codes that are returned in the ERA 835 file at the 2100 Claim Level. Settings in the Remittance Profiles Library and the Reason Codes Library work together to determine how these claim level codes are handled when the ERA file is imported and processed in NextGen® Enterprise PM. For example, when a denial code is returned at the 2100 claim level, it may be desirable to post the transaction to line items on the encounter with a status of Appeal so charge balances remain in the current payer bucket in Balance Control without moving to the subsequent payer or patient bucket. In the image below, code CO20 is setup in the Reason Codes library as a Claim Level code with a Transaction Detail Status of Appeal. The Apply Trans Detail Status (per claim) setting in the Remittance Profiles library determines which line items the Transaction Detail Status is applied to. <none>: Transaction detail status for claim level reason codes

Help Guide for NextGen® Enterprise PM 8

Setting Up Reason Codes for ERA

Reason codes are used by payers within the ERA 835 file to describe how the services are adjudicated. Payers are required to use HIPAA compliant codes in the ERA file that include a “Group” pre-fix, along with the actual code. (e.g. CO45) Group Codes: CO – Contractual Obligation PR – Patient Responsibility OA – Other Adjustment PI – Payer Initiated The HIPAA X12 Standard Reason Codes library in File Maintenance is pre-installed in the application and contains the industry standard Reason Codes. Important: The HIPAA X12 Standard Reason Codes library should never be hidden or renamed. The COB functionality in NextGen® Enterprise PM that is used for electronic secondary/tertiary claims, references the HIPAA X12 Standard Reason Codes library. It is important to remember that only HIPAA standard codes can be transmitted electronically for secondary/tertiary claims. Practice Level vs. Payer Level Libraries A Default Reason Code Library must be selected in Practice Preferences > Transactions.

File Maintenance Help for NextGen® Enterprise 8

Reason Code Library Maintenance Field Descriptions

Use the following table to enter reason codes into the library. Field Description Reason Code Library Enter the name for the library. Hide Library Select this check box to hide the library in the Reason Code List. Search Method: Description Select this option to run a search by reason code description. Search Method: Code Select this option to run a search by reason code. Search for keyphrase anywhere in the item Select this check box to search for a string of letters anywhere in the reason code description instead of searching based on the letters at the beginning of the description. This check box is available when you are modifying an existing reason code library. Type the first letter(s) of the Reason Code to locate Enter the first few letters of the reason code description to display the reason code you are searching for. If you selected the Search for keyphrase anywhere in the item check box, enter letters that occur within the description. Reason Codes List Lists the reason code

Help Guide for NextGen® Enterprise PM 8

Additional Information on Alternate Payer Transaction Options

The following table provides additional information on the alternate payer transaction options. Field Description ERA Payer Numbers The system checks the payer number in the ERA Payer Numbers field and the GS02 segment of the ERA file. If the payer number matches, then the payments are posted against the alternate payer. In the 835 IG, the ERA payer number can be located in the GS02 segment. Require both payments before settling If you select the Require both payments before settling check box, and the billing status shows up as waiting for another payment, then the default status on the line item is set to None to prevent further billing until you receive both the payments. Default Reason Code The default reason code exists at the line item level, and not at the transaction level. Therefore, when posting payments, the default reason code for the alternate payer will be applied to the line item. ERA Reason Code Library You must use the Reason Codes library when the payer number in the

File Maintenance Help for NextGen® Enterprise 8

Additional Information on Alternate Payer Transaction Options

The following table provides additional information on the alternate payer transaction options. Field Description ERA Payer Numbers The system checks the payer number in the ERA Payer Numbers field and the GS02 segment of the ERA file. If the payer number matches, then the payments are posted against the alternate payer. In the 835 IG, the ERA payer number can be located in the GS02 segment. Require both payments before settling If you select the Require both payments before settling check box, and the billing status shows up as waiting for another payment, then the default status on the line item is set to None to prevent further billing until you receive both the payments. Default Reason Code The default reason code exists at the line item level, and not at the transaction level. Therefore, when posting payments, the default reason code for the alternate payer will be applied to the line item. ERA Reason Code Library You must use the Reason Codes library when the payer number in the

Reason Code Types

Recommendations

Reason Code Options

2100 Claim Level Reason Codes

Setting Up Reason Codes for ERA

Reason Code Library Maintenance Field Descriptions

Additional Information on Alternate Payer Transaction Options

Additional Information on Alternate Payer Transaction Options

Reason Code Options

2100 Claim Level Reason Codes

Setting Up Reason Codes for ERA

Reason Code Library Maintenance Field Descriptions

Additional Information on Alternate Payer Transaction Options

Additional Information on Alternate Payer Transaction Options