NextGen Knowledge Center

Set Up Threshold Rules for a Program

On the Add/Modify Program Information window, the Threshold Rules sub-tab under the Practice tab enables you to configure payer-specific threshold rules for the program. For example, in a Behavioral Health practice, a payer may require that patients in a specific program have a minimum number of addiction counseling hours per week, or a minimum number of therapy units per month before billing the payer for those services.
  1. Access File Maintenance.
  2. Select System Master Files, then PM, and then Programs.
    The Program List window opens.
  3. From the list, select a program and then do one of the following:
    • Select Open Menu and then select Open.
    • Right-click and then select Open.
    • Double-click to open the program.
    The Modify Program Information window opens.
  4. Select the Practice tab, and then Threshold Rules on the left.
    Existing rules are listed in descending order by effective date with the following information:
    • Effective Date
    • Expiration Date
    • Threshold Description
      Modify Program Information window; Practice tab; Threshold Rules

  5. Do one of the following:
    • To create a threshold rule, select Open Menu and then select New.
    • To modify a threshold rule, select the rule from the list, then select Open Menu and then select Open.
    The Program Threshold Rules Maintenance window opens.
    Program Threshold Rules Maintenance window

  6. In the Effective Date field, enter the date the rule goes into effect. This field is required.
  7. In the Expiration Date field, enter the date the rule expires. This field is required.
  8. In the Description field, enter a description for the rule. This field is required.
  9. In the Valid Payers section, select the payers the rule applies to. This field is required and at least one payer must be selected.
    Do the following:
    • Select Open Record .

      The Payers window opens.

    • To add payers to the rule, search and select payers from the Available list on the left, and then select the Right Arrow button to move the payers to the Included list on the right.
    • To remove payers from the rule, select payers from the Included list on the right, and then select the Left Arrow button to move the payers to the Available list on the left.
    • To save changes and close the window, select OK.
  10. In the Program SIM section, select the SIM codes the rule applies to.
    The codes available for selection are from the Limit Service Items section on the System tab.

    If the rule applies to all SIM codes in the Limit Service Items list, leave this section blank.

    If the rule applies only to specific SIM codes in the Limit Service Items list, do the following:
    • Select Open Record .

      The Program SIM window opens.

    • To add SIM codes to the rule, search and select codes from the Available list on the left, and then select the Right Arrow button to move the codes to the Included list on the right.
    • To remove SIM codes from the rule, select codes from the Included list on the right, and then select the Left Arrow button to move the codes to the Available list on the left.
    • To save changes and close the window, select OK.
  11. In the Threshold Details section, do the following:
    • In the Minimum field, enter a value between 1 and 999. This field is required, and the value must be less than the maximum.
    • In the Maximum field, enter a value between 1 and 999. The value must be equal to or greater than the minimum.
    • In the Service Unit field, select one of the following:
      • Minutes
      • Hours (default)
      • Units
      • Encounters
    • In the Service Duration field, select one of the following:
      • Encounters
      • Week (default)
      • Months
  12. Do one of the following:
    • To save changes and close the window, select OK.
    • To save changes and add another rule, select Next.
    The rule displays in the Threshold Rules list.