Setting Up Claims

Help Guide for NextGen® Enterprise PM 8

Setting Up Claims

Before you can generate claims, you must set up options to define the following: The type of information you want to display in the various claim form fields The way you want the claim forms to print The location, payer, and provider information for a valid claim creation Specialty BillingFor more information about the setup and functionality of the types of billing based on specialty, go to NextGen Healthcare Success Community and download the following user guides. Anesthesia Billing User Guide for NextGen® Enterprise PM Behavioral Health Billing User Guide for NextGen® Enterprise PM Community Health Centers User Guide for NextGen® Enterprise PM Claim Printing Library The Claim Printing library enables you to specify options that define which information prints on claim forms. Claim Modifiers Library EDI Claim Profile Library The EDI Claim Profile library enables you to store and configure EDI claim settings in one central library. Contracts Library Claim Edits Set Up CPT Codes in Se

Help Guide for NextGen® Enterprise PM 8

Payers Master File

Payers are the third-party entities, other than guarantors or employers, that you expect to receive reimbursement from. Some examples of payers are commercial insurance companies, Medicaid, and Medicare. In the Payers master file, you can specify the contract associated with the payer, the participating providers, how to submit claims, and other general payer information. You can generate Payers Master File reports from the Payers master file. For more information, go to NextGen Healthcare Success Community and download the latest Reports User Guide for NextGen® Enterprise PM. Auditing Payers Master File Add or Modify a Payer Payer Defaults - 1 Tab Defaults - 2 Tab System Tab Practice Tab Configuring Alternate Payers You an use the Alternate Payer Simultaneous Billing feature to associate an alternate payer to a payer. External Tab for Payer Information Co-Pays Tab Changing the Payer Address and Associated Patient Records Activate and Assign a Payer to a Practice You can limit a practi

Help Guide for NextGen® Enterprise PM 8

EDI Claim Profile Library

The EDI Claim Profile library enables you to store and configure Electronic Data Interchange (EDI) claim settings in one central library. You can configure EDI claim settings based on payer requirements and control the setup involved when payers require service line level segments to be reported in the 837 claim file. The settings in this library also provide support for the 2400 loops and segments requested by payers when the details are different per charge. After you set up the EDI Claim Profile library, you can: Select a practice specific EDI Claim Profile library on the Libraries tab of the Practice Preferences window. Generate an EDI Claim Profile report to review the library name, dates, default EDI rules, and valid payers. Select the EDI Claim Profile library on the Alt Payer tab of the Add Payer Information or Modify Payer Information window. You can generate EDI Claim Profile Library Listing report from the EDI Claim Profile library. For more information go to NextGen Healthc

Help Guide for NextGen® Enterprise PM 8

Alternate Payers

The Payers-Alt Payers master file allows you to create an alternate payer and associate the alternate payer to a payer in the Payers master file. You can associate the same alternate payer to multiple payers or associate multiple alternate payers to a payer. When you bill an encounter with a payer having alternate payers, separate claims can be generated simultaneously. For example, you set up a payer to bill medical services such as an office visit (99213). Now, when you bill a behavioral health service for substance abuse therapy, the claim may go to a trading partner where the diagnosis is F11.10. But when the same substance abuse therapy is rendered for a patient with a mental health disorder, such as depression, the claim goes to the Department of Mental Health. You can also hide or show an alternate payer by selecting open menu and then selecting Hide or Un-hide. You can generate Alternate Payer Listing report from the Payers-Alt Payers master file. For more information, go to Ne

Help Guide for NextGen® Enterprise PM 8

Payers Master File

Payers are the third-party entities, other than guarantors or employers, that you expect to receive reimbursement from. Some examples of payers are commercial insurance companies, Medicaid, and Medicare. In the Payers master file, you can specify the contract associated with the payer, the participating providers, how to submit claims, and other general payer information. You can generate Payers Master File reports from the Payers master file. For more information, go to NextGen Healthcare Success Community and download the latest Reports User Guide for NextGen® Enterprise PM. Auditing Payers Master File Add or Modify a Payer Payer Defaults - 1 Tab Defaults - 2 Tab System Tab Practice Tab Configuring Alternate Payers You an use the Alternate Payer Simultaneous Billing feature to associate an alternate payer to a payer. External Tab for Payer Information Co-Pays Tab Changing the Payer Address and Associated Patient Records Activate and Assign a Payer to a Practice You can limit a practi

Help Guide for NextGen® Enterprise PM 8

Additional Information on Alternate Payer Billing Options

The following table provides additional information on the alternate payer billing options. Field Description Submitter Profile Library You must use the Submitter Profile library while creating electronic claims for the alternate payer. When you do not select the Submitter Profile library for the alternate payer, the alternate payer will use the Submitter Profile library of the payer. When you change the submitter profile in the Payers-Alt Payers master file, a message appears listing the number of pending alternate payer claims (with in the practice) whose submitter profile is flagged for processing. The message also states that if the user proceeds by changing the submitter profile, then the pending claims flagged for processing will be archived and the encounters associated with them will be flagged to rebill. Claim Edit Library When you do not select the Claim Edit library for the alternate payer, the alternate payer will use the Claim Edit library of the payer. Claim Print Library

Setting Up Claims

Specialty Billing

Recommendations

Setting Up Claims

Payers Master File

EDI Claim Profile Library

Alternate Payers

Payers Master File

Additional Information on Alternate Payer Billing Options

Setting Up Claims

Payers Master File

EDI Claim Profile Library

Alternate Payers

Payers Master File

Additional Information on Alternate Payer Billing Options