Set Up Encounter Rate SIM Maintenance Configurations

Help Guide for NextGen® Enterprise PM 8

Set Up the Claim SIM Options Tab

The Claim SIM Options tab on the Encounter Rate Billing Library Maintenance window contains options that provide the capability to show non-Encounter Rate SIMs on claims or affect automatic adjustments. Open an Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Claim SIM Options tab. In the Claim Service Range Options section, select open menu button and select New. The Alt Payer Number SIM Range window opens. Enter the SIM number or the beginning SIM number for a range of SIMs that you want to apply to a claim SIM option. For a range of SIM numbers, enter the ending SIM number. The ending SIM is required, but can be the same as the beginning SIM, functionally choosing that as a single SIM. Select OK. The claim SIM options are available for selection. Select the applicable option based on the following descriptions: Exclude from Encounter Rate Insertion: Select this option to make the service exempt from the Encounter Rate. This opti

Help Guide for NextGen® Enterprise PM 8

Set Up the COB Claims Tab

The COB Claims tab on the Encounter Rate Billing Library Maintenance window defines whether or not payers that may be subsequent to an encounter rate payer require the ER SIM code on their secondary/tertiary claims. For example, Medicare requires an Encounter Rate SIM code, or pay code, on qualified FQHC claims. Medicare then pays on that ER SIM. To create a balanced electronic secondary claim, the Medicare ER SIM must appear on the secondary claim with the appropriate CAS segments. In the case where the primary is an encounter rate payer and the secondary is not, but the secondary needs to see the ER SIM from the primary payer on the claim, the setup can be either of the following: Setup the Encounter Rate Library for the primary payer to insert the ER SIM as a charge, so the charge can be flagged to bill to the next payer. Setup the Encounter Rate Library for the primary payer to insert the ER SIM on Encounter Maintenance, and then setup an ER Library for the secondary payer to inser

Help Guide for NextGen® Enterprise PM 8

Set the SIM Configuration Hierarchy

Before you build an encounter rate, you must configure your hierarchy for diagnosis code, CPT4 code, location, provider, sex, and age. NextGen® Enterprise PM uses this hierarchy to determine which encounter rate SIM to use during billing. For example, if diagnosis has a higher position in the hierarchy than location, the application uses an Encounter Rate SIM that applies to a specific diagnosis for all locations instead of an encounter rate that applies to all diagnoses for a specific location. Note: In most cases, the default hierarchy does not need to be changed. Open the Encounter Rate Billing library. The Encounter Rate Billing List window opens. Select the Open Menu button and select New. The Encounter Rate Billing Library Maintenance window opens. Encounter Rate Billing Library Maintenance In the Encounter Rate SIM section, select the Set Configuration Hierarchy button. The SIM Configuration Hierarchy window appears. The hierarchy is set from the top down. SIM Configuration Hier

Help Guide for NextGen® Enterprise PM 8

Set Up the Primary Encounter Rate Tab

The Primary Encounter Rate tab on the Encounter Rate Billing Library Maintenance window contains billing rules that apply when the ER payer is the primary on the encounter. Open the Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Primary Encounter Rate tab. Set the Suppress Claim Creation setting. The option is: Suppress claim for multiple same-day encounters (Multi-Yes only): Select this option to suppress the creation of a claim for an encounter with a status of Multi-no if there are multiple encounters per day. Set the Encounter Rate Calculation setting. The option is: Add 20% of original charge line items to encounter rate amount: Select this option to calculate 20% of the original charge amounts and add that to the encounter rate amount before inserting the new charge on the encounter. Set the Auto Adjustments settings. These settings have no impact on alternate payer charge lines. The option is: Adjust remaining balance of c

Help Guide for NextGen® Enterprise PM 8

Set Up the Claims Tab

The Claims tab on the Encounter Rate Billing Library Maintenance window contains a series of questions designed for configuring claims for the ER payer. Primary, secondary and tertiary claims for the payer can be configured separately. Open the Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Claims tab. Existing Claim Detail Rules sets display as separate rows, with the current active row at the top of the list. Rows can be sorted by selecting on the Eff Date, Exp Date or Description column headings. Do one of the following: To add a Claim Detail Rules set, select open menu button and select New. To modify a Claim Detail Rules set, select the row from the list, and then select open menu button and select Open. To copy a Claim Detail Rules set, select the row from the list, and select open menu button and select Copy. The Encounter Rate Claim Detail Rules window opens. In the Effective Date and Expiration Date fields, enter an effe

Help Guide for NextGen® Enterprise PM 8

Add or Modify an Encounter Rate Billing Library

The Encounter Rate Billing library enables you to configure the billing process for payers who require a flat encounter rate. This library is used to configure the business rules applicable to a payer. The Encounter Rate Billing library provide the flexibility to set up multiple rate codes to accommodate the different billing requirements of individual payers. The appropriate library can then be attached to the payer. A SIM with the appropriate CPT4 code must be set up in the SIM library before you set up encounter rate billing. Note: When you copy an Encounter Rate Billing library, the SIM Configuration Hierarchy and the encounter rate information are also copied. To add or modify an Encounter Rate Billing library, do the following: Access File Maintenance. Select Libraries, and then Encounter Rate Billing. The Encounter Rate Billing List window opens. Do one of the following: To add a library, select Open Menu and select New. To modify a library, select the library from the list, and

Set Up Encounter Rate SIM Maintenance Configurations

Recommendations

Set Up the Claim SIM Options Tab

Set Up the COB Claims Tab

Set the SIM Configuration Hierarchy

Set Up the Primary Encounter Rate Tab

Set Up the Claims Tab

Add or Modify an Encounter Rate Billing Library

Set Up the Claim SIM Options Tab

Set Up the COB Claims Tab

Set the SIM Configuration Hierarchy

Set Up the Primary Encounter Rate Tab

Set Up the Claims Tab

Add or Modify an Encounter Rate Billing Library