Claim Header Rules and Claim Consolidation Rules

Help Guide for NextGen® Enterprise PM 8

CSC Terms

The following table provides a list of terms associated with the consolidation process of claims. Term Description TS Time Span - claims that occur on the same date, week, month, or case. The time-span is identified in the CSC library. CCCP Case Claim Consolidation Program – The program rules established in the Consolidated Services Claim library to consolidate all claims attached to a Case. CCR Consolidated Claims Rules CSC Consolidated Services Claim CSC Candidate Encounter When a patient has multiple encounters per day. Each encounter can be a CSC candidate encounter. CSC Hold Claims These are the claims created after billing a CSC Candidate Encounter but prior to running the CSC process. Consolidated Claim After the charges from the CSC Hold Claims are consolidated into a CSC, the CSC Hold Claims become Consolidated claims. Claim-Header Encounter The claim header details are derived from this encounter. Primary Attending is selected in the Primary Responsible Attending field from t

Help Guide for NextGen® Enterprise PM 8

Exempting CSC Encounters

CSC options can be set manually on the Consolidated Services Claim tab under the Claims tab on the Encounter Maintenance window. The options set on this tab override the rules in the Consolidated Services Claims library. On the Consolidated Services Claim sub-tab, you can you can do the following: Identify the responsible attending physician to display in the claim header for primary, secondary, and tertiary payers. Identify specific encounters to be exempt from a consolidated services claim. If there is an eligibility overlap during billing, the application displays the following error in the Claim Production Status report: CSC Eligibility Dates overlap with HOLD claims for encounter(s). Correct Eligibility. Parent topic: Claims Consolidated Services Claim Sub-Tab Parent topic: Consolidated Service Claims

Help Guide for NextGen® Enterprise PM 8

Consolidated Services Claim Library

The Consolidated Services Claim (CSC) library enables you to establish rules for consolidating multiple encounter charges into a single consolidated services claim (CSC). The purpose of this library is to configure billing and claim form type rules for payers. This section includes the following topics: Security rights for user groups Consolidated Services Claim library CSC configuration rules for the consolidation of daily, weekly, monthly, and case related claims Provider hierarchy for claim headers Bill for eligible patient days You can generate the Consolidated Services Claim Library Listing report and the CSC Library with Timespan Details report from the Consolidated Services Claim library. For more information go to NextGen Healthcare Success Community and download the latest Reports User Guide for NextGen® Enterprise PM. Set Up Security Access Rights for Consolidated Services Claims The Consolidated Services Claims security rights must be assigned to a user's group for combining

Help Guide for NextGen® Enterprise PM 8

Mark a CSC Encounter as Exempt

CSC candidate encounters can be marked exempt either manually or automatically by the system. Automatic exemption of a claim occurs when the claim is suppressed as a result of File Maintenance settings. Exempt encounter charges are not included in a consolidated claim. Access the Consolidated Services Claim tab under the Claims tab on the Encounter Maintenance window. To identify the responsible attending provider for claim header, complete the Primary Responsible Attending, Secondary Responsible Attending, and Tertiary Responsible Attending fields. Select one of the following options for each applicable insurer: None - (default prior to billing) Responsible Attending Ancillary Provider To remove encounter charges from a primary, secondary, or tertiary CSC claim, select the applicable check box: Exempt from Primary Consolidated Services Claim An alert displays if a Primary HOLD claim is attached to the encounter: A HOLD claim exists for this encounter. Would you like to convert the HOL

File Maintenance Help for NextGen® Enterprise

Claim Header Rules and Claim Consolidation Rules

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. These hierarchy rules will apply to all of the payers in the Valid Payers list. Establishing a Provider Hierarchy The following rules apply when setting up the provider hierarchy: The provider hierarchy is blank when creating a new library. A specialty can only display one time in the hierarchy. Specialties hidden in the Specialties master file do not display in the Select Responsible Attending Provider by Specialty list. You must select at least one specialty from the Select Responsible Attending Provider by Specialty list. When a Provider Hierarchy is NOT Established When a provider hierarchy is not established, in NextGen® Enterprise PM the user must enter a Primary Provider, for one of the encounters, in the Primary Responsible Attending field on the Consolidated Services Claim sub-tab on the Claim

File Maintenance Help for NextGen® Enterprise 8

Claim Header Rules and Claim Consolidation Rules

Use the Claim Header Rules tab to establish a provider hierarchy and identify the attending provider for consolidated service claims (CSC). 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. These hierarchy rules will apply to all of the payers in the Valid Payers list. Establishing a Provider Hierarchy When a Provider Hierarchy is NOT Established Add Claim Consolidation Rules to a CSC Library Add Claim Header Rules to a CSC Library Eligible Number of Patient Days Billing Parent topic: Consolidated Services Claim Library

Claim Header Rules and Claim Consolidation Rules

Establishing a Provider Hierarchy

When a Provider Hierarchy is NOT Established

Recommendations

CSC Terms

Exempting CSC Encounters

Consolidated Services Claim Library

Mark a CSC Encounter as Exempt

Claim Header Rules and Claim Consolidation Rules

Claim Header Rules and Claim Consolidation Rules

Claim Header Rules and Claim Consolidation Rules

Establishing a Provider Hierarchy

When a Provider Hierarchy is NOT Established

CSC Terms

Exempting CSC Encounters

Consolidated Services Claim Library

Mark a CSC Encounter as Exempt

Claim Header Rules and Claim Consolidation Rules

Claim Header Rules and Claim Consolidation Rules