Setting Up Reason Codes for ERA

Help Guide for NextGen® Enterprise PM 8

Setting Up Practice Preferences for ERA

You can configure the following ERA settings in Practice Preferences. Go to Practice Preferences, then Libraries and select Remittance Profile Library to set the default library to be used for all ERA payers that do not have a specific library linked in the practice. Go to Practice Preferences, then Transactions and select Default Reason Code Library to set the default library to be used for all payers (ERA and non-ERA) in the practice, that do not have a specific library linked. Note: NextGen Healthcare recommends the use of the HIPAA X12 Standard Reason Codes library as the default for a practice for all payers. Use settled up status with ERA. You can select this check box to default the Settled moved to Primary transaction status onto ERA payment or adjustment transactions received from the secondary payer before the primary payer. When a secondary transaction is received before primary, a credit balance is normally created in the secondary payer (Ins2 Amt) bucket in Balance Control

Help Guide for NextGen® Enterprise PM 8

Set Up a Remittance Profile Library

The Remittance Profile Library defines various parameters and rules that are used when importing and processing ERA 835 files downloaded from payers into NextGen® Enterprise PM. The Default Remittance Profile library in File Maintenance is pre-installed in the application and includes a few recommended pre-set options. All remaining options are set based on your organizational preferences or in response to the payer’s ERA 835 file configuration. Practice Level vs. Payer Level Libraries A default Remittance Profile Library must be selected in Practice Preferences > Libraries. The default library is used for all ERA payers in the practice that do not have a specific library linked. A different Remittance Profile Library to be used for a specific payer/financial class can be linked on the Payer > Practice > Libraries sub-tab. This library overrides the default library in Practice Preferences for the payer/financial class. Any payers that do not have a Remittance Profile Library attached u

Help Guide for NextGen® Enterprise PM 8

Setting Up Reason Codes for ERA

Reason codes are used by payers within the ERA 835 file to describe how the services are adjudicated. Payers are required to use HIPAA compliant codes in the ERA file that include a “Group” pre-fix, along with the actual code. (e.g. CO45) Group Codes: CO – Contractual Obligation PR – Patient Responsibility OA – Other Adjustment PI – Payer Initiated The HIPAA X12 Standard Reason Codes library in File Maintenance is pre-installed in the application and contains the industry standard Reason Codes. Important: The HIPAA X12 Standard Reason Codes library should never be hidden or renamed. The COB functionality in NextGen® Enterprise PM that is used for electronic secondary/tertiary claims, references the HIPAA X12 Standard Reason Codes library. It is important to remember that only HIPAA standard codes can be transmitted electronically for secondary/tertiary claims. Practice Level vs. Payer Level Libraries A Default Reason Code Library must be selected in Practice Preferences > Transactions.

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

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

Reason Code Types

There are four types of reason codes as described below. The type of code that is used is determined by the payer. Different payers may return the same code as either a Line Item code or a Claim Level code. If this occurs, it is possible to have the same code in the Reason Code Library with two different code types to ensure that the ERA 835 file processes correctly. Adjudication codes are always claim level codes. Remark codes are always line item level codes. Reason codes that are imported “on-the-fly” are automatically flagged as either Line Item or Claim Level, depending on how they are returned by the payer in the ERA file. Line Item: Line Item reason codes are returned by the payer at the charge, or CPT® 4 code, level. They are available for selection in the Line Item Reasons column at the bottom of the Payment Entry window. They display in the Reason column in the Patient Chart > Encounters > Transactions sub-tab. Claim Level: Claim Level reason codes are returned by the payer a

Setting Up Reason Codes for ERA

Practice Level vs. Payer Level Libraries

Recommendations

Setting Up Practice Preferences for ERA

Set Up a Remittance Profile Library

Setting Up Reason Codes for ERA

Configuring Business Rules for Denial Management

Reason Code Options

Reason Code Types

Setting Up Reason Codes for ERA

Practice Level vs. Payer Level Libraries

Setting Up Practice Preferences for ERA

Set Up a Remittance Profile Library

Setting Up Reason Codes for ERA

Configuring Business Rules for Denial Management

Reason Code Options

Reason Code Types