Retrieving Charge Amount in Cost Estimation

Help Guide for NextGen® Enterprise PM 8

Retrieving Patient Benefits for Cost Estimation

Co-pay, deductible, and coinsurance are collectively referred to as patient benefits. Co-pay is the fixed amount the patient must pay for each visit, which is predetermined in the co-pay clause of the insurance policy. Deductible is the fixed amount a patient must pay each year before the insurance payer begins to cover the costs. After the patient pays the deductible amount as per the insurance plan, the payer starts to share the cost of the service. Coinsurance is the fixed cost for treating the covered services that the patient must bear after the deductible amount is paid. Non-covered charges are incurred on services that do not have insurance coverage. For a practice running in a real-time system, co-pay, deductible, coinsurance, and non-covered charges are retrieved from the real-time eligibility (271) transaction file. For a practice running in a non-real-time system, the patient benefits are retrieved as follows: The co-pay is retrieved from the patient's insurance information,

Help Guide for NextGen® Enterprise PM 8

Retrieving Allowed Amount in Cost Estimation

Allowed amount is the amount expected to be paid by the insurance provider and patient for an individual service. The allowed amount for a service can be retrieved from the transaction history or contract library and contract exception (collectively known as contract). If you are the administrator, you can select the source for the allowed amount in the practice preferences and get the allowed amount as follows: If you select contract, the allowed amount is retrieved from the contract library or contract exception. If you select transaction history, the allowed amount is retrieved from the transaction history based on the date range you select. If found, the allowed amount is calculated based on your selection of the following options: Average of all amounts: Returns the average of the allowed amounts for a service. Latest allowed amount: Returns the allowed amount from the latest transaction. If you select both, the system looks for the allowed amount in both sources. You can also sel

Help Guide for NextGen® Enterprise PM 8

Cost Estimation Data Sources

The information for cost estimation can be retrieved from: Service Items (SIM) library A library that enables you to add SIM codes with associated CPT®4 code for each practice, along with prices. You can also group service items under one main number or name. SIM exception A library that enables you to charge different fees according to provider, location, and payer. Additional fees are referred to as exceptions, which can be set up and maintained through the SIM Library. Contract library A library that enables you to set up payers for the contract and indicates the reimbursement amount for the procedures. Contract exception A library that enables you to charge different fees based on the provider, location, and payer. Each additional fee is referred to as an exception to the contract and can be set up and maintained through the Contract library. After the exceptions are set up, you can assign a contract exception to providers at the provider, payer, or location level to apply the exce

Help Guide for NextGen® Enterprise PM 8

SIM Groups for Service Items

You can initiate the cost estimation for a patient or person using an appointment, encounter, a person or people lookup, or the taskbar menu. Irrespective of what you use to initiate the process, you can set up a Service Item Group (SIM Group) code that includes all SIM codes and the descriptions for all services. It makes the cost estimation process more efficient and error-free as you enter charges for multiple services that are typically performed together. In File Maintenance, you can configure a SIM Group based on the location or payer. For more information on configuring a SIM Group based on location or payer, go to NextGen Healthcare Success Community, and download the latest File Maintenance Libraries Guide for NextGen® Enterprise. When you enter a SIM Group in the Service Items section on the Estimate Patient Cost window, the SIM Group expands and displays the SIM codes in the SIM Group. A SIM Group displays the SIM codes on the Estimate Patient Cost window based on the follow

Help Guide for NextGen® Enterprise PM 8

Recalculation Results Report

The Recalculation Results report displays messages related to encounters that may have been evaluated for recalculation of new charge prices based on changes made. The report has two purposes: To show SIM price derivation. To let users know if there was a problem that caused recalculation to fail. Recalculation happens when the following events take place: An In Progress encounter is manually recalculated by using the Recalc Enc button on the Charge Posting window, or the Recalculate ‘In Progress’ Encounter menu option. An In Progress encounter is converted to Unbilled. The encounter change process is performed. Encounter insurances are re-ordered. The Prorate button is selected on the Balance Control window. Changes are made to an unprocessed charge, such as date of service, place of service or location that could result in a different SIM library or price derivation. To access the report in NextGen® Enterprise PM, select the Reports menu and select General and then select Person Empl

Help Guide for NextGen® Enterprise PM 8

Charge Options Field Descriptions

Use the following table to setup charge options. Field Description Disable Variance Calculation This check box controls whether or not a variance will be calculated for payers using this library. To enable variance calculations, leave this check box blank and complete all remaining fields on the tab. During the billing process, variance will be calculated, and a variance SIM will be added to the encounter if a positive or negative variance exists. To disable variance calculations, select this check box. All remaining fields on the tab become unavailable. During the billing process, variance will not be calculated, and a variance SIM will therefore not be added to the encounter. Note: If selected, the Claim Production Status report in NextGen® Enterprise PM displays the following green message when the encounter passes claim edits: Behavioral health variance charge not inserted due to library settings. Insert SIM with Variance Amount on Roll-up Charges Service Item # Select the SIM code

Retrieving Charge Amount in Cost Estimation

Recommendations

Retrieving Patient Benefits for Cost Estimation

Retrieving Allowed Amount in Cost Estimation

Cost Estimation Data Sources

SIM Groups for Service Items

Recalculation Results Report

Charge Options Field Descriptions

Retrieving Patient Benefits for Cost Estimation

Retrieving Allowed Amount in Cost Estimation

Cost Estimation Data Sources

SIM Groups for Service Items

Recalculation Results Report

Charge Options Field Descriptions