Select Transaction Status for Default Option

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

Configuring Business Rules for Denial Management

With the implementation of ERA, it is necessary to create a set of business rules that will direct NextGen® Enterprise PM on how to handle adjudicated claims, particularly denials. These adjustments and denials are identified by the payers with HIPAA standard reason codes. In NextGen® Enterprise PM, ERA adjustments are automatically posted for reason codes pre-fixed with CO (contractual obligation), OA (other adjustment) and PI (payer initiated). Adjustments are not taken for reason codes pre-fixed with PR (patient responsibility). NextGen® Enterprise PM also moves the remaining balance to the next responsible payer automatically when an ERA transaction is posted; from COB1 to COB2 (if a secondary payer exists), from COB2 to COB3 (if a tertiary payer exists), and finally to patient responsibility. In order to fully automate the ERA Posting process, certain selections must be made in the Reason Codes Library to ensure that only the appropriate reason codes are taking adjustments and tha

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

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

Help Guide for NextGen® Enterprise PM 8

Set Up Default Payment/Adjustment Transaction Codes

Access File Maintenance. Select System Master Files > PM > Payers. The Payers List window opens. From the list, select and open the desired payer. The Modify Payer Information window opens. Select the Practice tab, and then select the Transactions sub-tab. Use the following table to select Transactions parameters for the payer. To save changes and close the window, select OK. Field Description Default Payment Select a third-party payment transaction code for the payer. The code defaults to the Pay Code field on the Payment Entry screen for manually entered payments and for ERA payments received from the payer. This field is required. Default Adjustment Select a third-party adjustment transaction code for the payer. The code defaults to the Adj Code field on the Payment Entry screen for manually entered adjustments and for ERA adjustments received from the payer. This field is required. Default Payment for Bad Debt Select a third-party bad debt payment transaction code for the payer. Th

Select Transaction Status for Default Option

Recommendations

Reason Code Options

Configuring Business Rules for Denial Management

2100 Claim Level Reason Codes

Additional Information on Alternate Payer Transaction Options

Additional Information on Alternate Payer Transaction Options

Set Up Default Payment/Adjustment Transaction Codes

Reason Code Options

Configuring Business Rules for Denial Management

2100 Claim Level Reason Codes

Additional Information on Alternate Payer Transaction Options

Additional Information on Alternate Payer Transaction Options

Set Up Default Payment/Adjustment Transaction Codes