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State-Specific Billing Forms

Reports are available from the NextGen Healthcare Claims Department for the following state-specific forms:

Alabama

Form 340

Illinois

Form 2211
Form 2360
Form 3797

Massachusetts

Form 5
Form 9

Michigan

Form BCBS Status Inquiry

New York

Form C4
Form C4.1
Form C4.2
Form C4.3
Form C5
Form No Fault Billing
Medicaid Title XIX

Ohio

Form UCF
Form 6780

Texas

Form 2017
Texas Medicaid & Healthcare Partnership (TMHP) Form

In addition, stored procedures are available to accommodate electronic claim requirements for the following:

Texas Medicaid Family Planning
Provider Public Partners - Los Angeles County Department of Health

State-Specific Billing Forms

Help Guide for NextGen® Enterprise PM 8

State-Specific Reports

Many states have proprietary reports that Health Centers are required to submit to keep their state funding. For example, many state Medicaid plans have special reporting requirements. If these reports cannot be produced by use of the standard reports within NextGen® Enterprise PM, then they may require a custom report. Below is a list of reports that may be required in some states: California Office of Statewide Health Planning and Development (OSHPD)* Title X Family Planning Annual Report* Massachusetts Health Safety Net Organization Texas Title X Family Planning Annual Report* Title XX Below is a list of reports that may be required by IHS practices: Government Performance and Results Act (GPRA)* National Data Warehouse (NDW) Diabetic Audit Report (DAR)* Contract Health Referral System (CHRS)* Note: Reports indicated with an asterisk (*) are available from NextGen Technical Consulting Services. State-Specific Billing Forms Parent topic: Health Center Reporting

Help Guide for NextGen® Enterprise PM 8

Custom Reports

Custom reports are available for Health Centers from NextGen Technical Consulting Services. Medicare / Medicaid (Medi-Medi) Report: This report identifies patients who have Medicare as their primary payer and Medicaid as their secondary payer. Encounter Rate Analysis Report: This report generates financial information related to encounter rate billing. Information includes, but is not limited to, the following; Transaction Totals, Total Charges, Encounter Rate Charges, Net Adjustments, Encounter Rate Adjustments, and True Adjustments for a specified date range. Unduplicated Patient Count Report: This report generates a listing and count of patients seen within a specified date range. Each patient is listed only once regardless of the number encounters they have. Patient Demographics Report Title X Report: This report is required annually for grants regarding family planning under Title X, as specified in OMB document no. 0990-0221. Note: The Title X template in NextGen® Enterprise must

NextGen® Enterprise EHR Help

RxPrint and RxFax Reports for Individual States

In addition to the basic state reporting requirements, some states require different formats or other specific information, such as: How the signature lines and dispense instructions display on the report. Specific information requested by a state, such as a supervising physician's signature or maximum dosage for controlled substances. Example 1: The Washington state regulations require the Washington RxPrint and RxFax report to include the following text for a controlled substance script: Photo identification required of the person picking up the prescription. Example 2: The New Jersey RxPrint and RxFax reports include the collaborating physician and the collaborating physician’s information. Example 3: To meet the New Mexico requirements, the New Mexico RxPrint and RxFax reports include the name, business address and telephone number of the supervising physician in the report footer. Refill options. On the Indiana RxPrint and RxFax report, providers can circle the appropriate Refill

File Maintenance Help for NextGen® Enterprise 8

Claims Sub-Tab

Field Description Process as Claim Type Enter the type of claim to process for this payer. When you make a selection, the system populates the Billing tab with the Qualifier as Employers ID Number (EI) and the Data Element as Tax ID. Both 4010 and 5010 claim formats require the EI and Tax ID to be populated for the Billing Loop. The secondary reference qualifiers can be manually set or they may be set using a claims utility if additional qualifiers and data elements are needed. Note: If you select Blue Cross/Blue Shield (BL), then the Plan Code field changes to BCBS Plan Code. If you select one of these claim types (Blue Cross/Blue Shield, Champus, Commercial, Medicaid, Medicare, or Worker's Compensation), then default values for the claim type are automatically filled in for the Provider Secondary References section. If there are existing secondary references, they are replaced with new ones. Financial Class Enter the financial class associated with this payer. Insurance Type Code Ent

Help Guide for NextGen® Enterprise PM 8

Claims Sub-Tab

Field Description Process as Claim Type Enter the type of claim to process for this payer. When you make a selection, the system populates the Billing tab with the Qualifier as Employers ID Number (EI) and the Data Element as Tax ID. Both 4010 and 5010 claim formats require the EI and Tax ID to be populated for the Billing Loop. The secondary reference qualifiers can be manually set or they may be set using a claims utility if additional qualifiers and data elements are needed. Note: If you select Blue Cross/Blue Shield (BL), then the Plan Code field changes to BCBS Plan Code. If you select one of these claim types (Blue Cross/Blue Shield, Champus, Commercial, Medicaid, Medicare, or Worker's Compensation), then default values for the claim type are automatically filled in for the Provider Secondary References section. If there are existing secondary references, they are replaced with new ones. Financial Class Enter the financial class associated with this payer. Insurance Type Code Ent

NextGen® Enterprise EHR Help

RxPrint and RxFax Reports for Individual States

In addition to the basic state reporting requirements, some states require different formats or other specific information, such as: How the signature lines and dispense instructions display on the report. Specific information requested by a state, such as a supervising physician's signature or maximum dosage for controlled substances. Example 1: The Washington state regulations require the Washington RxPrint and RxFax report to include the following text for a controlled substance script: Photo Identification required of the person picking up the prescription. Example 2: The New Jersey RxPrint and RxFax reports include the collaborating physician and the collaborating physician’s information. Example 3: To meet the New Mexico requirements, the New Mexico RxPrint and RxFax reports include the name, business address and telephone number of the supervising physician in the report footer. Refill options. On the Indiana RxPrint and RxFax report, providers can circle the appropriate Refill