Configure Non-Encounter Rate SIMs and Automatic Adjustments

Help Guide for NextGen® Enterprise PM 8

Set Up the Primary Encounter Rate Billing Options

Open File Maintenance. Select Libraries > Encounter Rate Billing.The Encounter Rate Billing List window opens. Do one of the following: To add a library, select the open menu button and then select New. To modify a library, select the library from the list, select the open menu button , and then select Open. The Encounter Rate Billing Library Maintenance window opens. Select the Primary Encounter Rate tab. In the Suppress Claim Creation setting, select the Suppress claim for multiple same-day encounters (Multi-Yes only) option to suppress the creation of a claim for an encounter with a status of Multi-no if there are multiple encounters in a day. In the Encounter Rate Calculation setting, select the Add 20% of original charge line items to encounter rate amount option to calculate 20% of the original charge amounts and add it to the encounter rate amount before inserting the new charge on the encounter. Set the Auto Adjustments settings to one of the following. These settings have no i

Help Guide for NextGen® Enterprise PM 8

Set Up the COB Claims Tab

The COB Claims tab on the Encounter Rate Billing Library Maintenance window defines whether or not payers that may be subsequent to an encounter rate payer require the ER SIM code on their secondary or tertiary claims. To set up COB claim rules for subsequent payers to the ER payer, do the following: Open File Maintenance. Select Libraries > Encounter Rate Billing. The Encounter Rate Billing List window opens. Do one of the following: To add a library, select the open menu button and then select New. To modify a library, select the library from the list, select the open menu button , and then select Open. The Encounter Rate Billing Library Maintenance window opens. Select the COB Claims tab. Select Subsequent Payers require Enc Rate SIM. The Except Payers that do not accept Encounter Rate SIM section becomes available. Select open folder icon. Note: The Open Folder is available only if the Subsequent Payers require Enc Rate SIM check box is selected. The Payers window opens. In the Fin

Help Guide for NextGen® Enterprise PM 8

Set Up Encounter Rate SIM Maintenance Configurations

After you set the SIM configuration hierarchy, you must set up specific parameters for the encounter rate SIM code. Open File Maintenance. Select Libraries > Encounter Rate Billing. The Encounter Rate Billing List window opens. Select a library from the list. The Encounter Rate Billing Library Maintenance window opens. Right-click the Encounter Rate SIM grid, and then select New. The Encounter Rate SIM Maintenance window opens. Encounter Rate SIM Maintenance window Enter the service item number. Select the effective and expiration dates. Enter the co-pay amount. Select a condition code for Field Locator 18 on UB claims. Note: The Description and Amount fields are automatically filled in based on the service item description for the encounter and the corresponding dollar value from the SIM. You can modify the values. Optional: In the Required CPT4 section, select the open record button, and then select the codes. Select the payer in COB. Optional: In the Valid Primary Payers section, se

Help Guide for NextGen® Enterprise PM 8

Set Up the General Billing Rule Options

Open File Maintenance. Select Libraries > Encounter Rate Billing. The Encounter Rate Billing List window opens. Do one of the following: To add a library, select the open menu button and then select New. To modify a library, select the library from the list, select the open menu button and then select Open. The Encounter Rate Billing Library Maintenance window opens. Select the General tab. In the Encounter Rate Exempt setting, do the following: Disqualify patient encounter from ER billing if: Select one of the following options to set the basis for disqualifying an encounter from encounter rate billing: All SIMs are ER exempt Only one SIM is ER exempt Suppress claim for disqualified patient encounter: Select this option to suppress the claim for any encounter that is disqualified from encounter rate billing based on exempt SIM codes. Note: Encounter Rate Exempt settings apply only when one or more of the charge line SIM codes are flagged as Enc rate exempt in the Service Items library

File Maintenance Help for NextGen® Enterprise 8

Set Up the Claim SIM Options Tab

The Claim SIM Options tab on the Encounter Rate Billing Library Maintenance window contains options that provide the capability to show non-Encounter Rate SIMs on claims or affect automatic adjustments. Open an Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Claim SIM Options tab. In the Claim Service Range Options section, select open menu button and select New. The Alt Payer Number SIM Range window opens. Enter the SIM number or the beginning SIM number for a range of SIMs that you want to apply to a claim SIM option. For a range of SIM numbers, enter the ending SIM number. The ending SIM is required, but can be the same as the beginning SIM, functionally choosing that as a single SIM. Select OK. The claim SIM options are available for selection. Select the applicable option based on the following descriptions: Exclude from Encounter Rate Insertion: Select this option to make the service exempt from the Encounter Rate. This opti

Help Guide for NextGen® Enterprise PM 8

Set Up the Claim SIM Options Tab

The Claim SIM Options tab on the Encounter Rate Billing Library Maintenance window contains options that provide the capability to show non-Encounter Rate SIMs on claims or affect automatic adjustments. Open an Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Claim SIM Options tab. In the Claim Service Range Options section, select open menu button and select New. The Alt Payer Number SIM Range window opens. Enter the SIM number or the beginning SIM number for a range of SIMs that you want to apply to a claim SIM option. For a range of SIM numbers, enter the ending SIM number. The ending SIM is required, but can be the same as the beginning SIM, functionally choosing that as a single SIM. Select OK. The claim SIM options are available for selection. Select the applicable option based on the following descriptions: Exclude from Encounter Rate Insertion: Select this option to make the service exempt from the Encounter Rate. This opti

Configure Non-Encounter Rate SIMs and Automatic Adjustments

Recommendations

Set Up the Primary Encounter Rate Billing Options

Set Up the COB Claims Tab

Set Up Encounter Rate SIM Maintenance Configurations

Set Up the General Billing Rule Options

Set Up the Claim SIM Options Tab

Set Up the Claim SIM Options Tab

Set Up the Primary Encounter Rate Billing Options

Set Up the COB Claims Tab

Set Up Encounter Rate SIM Maintenance Configurations

Set Up the General Billing Rule Options

Set Up the Claim SIM Options Tab

Set Up the Claim SIM Options Tab