NextGen Knowledge Center

Add Claim Header Rules to a CSC Library

The Claim Header Rules establish a provider hierarchy and these hierarchy rules are applied to all the payers in the Valid Payers list. The physician with the highest-ranking specialty is automatically listed as the attending provider in the header data of the CSC claim. All CSC claims are sent to the payer as EDI files.

  1. In File Maintenance, select Libraries > Consolidated Services Claim.
    The Consolidated Services Claim List window opens.
  2. Select the applicable library.
  3. Select Open Menu , and then select Open.
    The Consolidated Services Claim Library Maintenance window opens.
  4. In Consolidated Services Claim Library Maintenance, select Open Menu , and then select Open.
    The Consolidated Services Claim Maintenance window opens.
  5. Select Claim Header Rules.
  6. In Select Responsible Attending Provider by Specialty, select Open Folder .
    The Attending Specialty Hierarchy window opens.

  7. In the Attending Specialty Hierarchy window, do one of the following:
    • To add a specialty to the Included list, select the specialty in the Available list, and then select Include .
    • To remove a specialty from the Included list, select the specialty in the Included list, and then select Exclude .
  8. Select OK.
    The Consolidated Services Claim Maintenance window displays with the selected specialties in hierarchical order.
  9. The default check box Responsible Attending from Encounter with greatest dollar value when two provides of the same specialty are found across same-day encounters is automatically selected.
    • When this check box is enabled the following applies:
      • This option is unavailable until at least one specialty is selected on the Attending Specialty Hierarchy window.
      • When two or more CSC candidate encounters have the same provider specialty, the provider from the CSC candidate claim with the greatest total dollar value populates the claim header.
      • When two encounters with the same specialty and the same dollar amount (double-tie) occur on a CSC candidate claim, the encounter with the lowest encounter number populates the claim header.
    • When this check box is disabled, the following applies:
      • When two or more CSC candidate encounters have the same provider specialty the responsible attending provider must be manually selected from the Primary Responsible Attending field under the Consolidated Services Claim sub-tab on the Claims tab of the Encounter Maintenance window.
  10. To consolidate the claims when encounters or claims have different payers, select Ignore COB order for consideration. Use other payers from Encounter with Responsible Attending on consolidated claims.
  11. Select OK.
Add Claim Header Rules to a CSC Library