Cost Estimation Data Sources

Service Items (SIM) library	A library that enables you to add SIM codes with associated CPT®4 code for each practice, along with prices. You can also group service items under one main number or name.
SIM exception	A library that enables you to charge different fees according to provider, location, and payer. Additional fees are referred to as exceptions, which can be set up and maintained through the SIM Library.
Contract library	A library that enables you to set up payers for the contract and indicates the reimbursement amount for the procedures.
Contract exception	A library that enables you to charge different fees based on the provider, location, and payer. Each additional fee is referred to as an exception to the contract and can be set up and maintained through the Contract library. After the exceptions are set up, you can assign a contract exception to providers at the provider, payer, or location level to apply the exceptions to charges.
Transaction history	A repository where previous eligibility verification transactions are recorded.
Real time eligibility verification (271) transaction	Electronic response file comprising coverage, eligibility, and benefits information.
Insurance information of the person or patient	Insurance information required for cost estimation is collected and maintained in the Insurance Maintenance window.

Help Guide for NextGen® Enterprise PM 8

Retrieving Patient Benefits for Cost Estimation

Co-pay, deductible, and coinsurance are collectively referred to as patient benefits. Co-pay is the fixed amount the patient must pay for each visit, which is predetermined in the co-pay clause of the insurance policy. Deductible is the fixed amount a patient must pay each year before the insurance payer begins to cover the costs. After the patient pays the deductible amount as per the insurance plan, the payer starts to share the cost of the service. Coinsurance is the fixed cost for treating the covered services that the patient must bear after the deductible amount is paid. Non-covered charges are incurred on services that do not have insurance coverage. For a practice running in a real-time system, co-pay, deductible, coinsurance, and non-covered charges are retrieved from the real-time eligibility (271) transaction file. For a practice running in a non-real-time system, the patient benefits are retrieved as follows: The co-pay is retrieved from the patient's insurance information,

Help Guide for NextGen® Enterprise PM 8

Cost Estimation Data Sources

The information for cost estimation can be retrieved from: Service Items (SIM) library A library that enables you to add SIM codes with associated CPT®4 code for each practice, along with prices. You can also group service items under one main number or name. SIM exception A library that enables you to charge different fees according to provider, location, and payer. Additional fees are referred to as exceptions, which can be set up and maintained through the SIM Library. Contract library A library that enables you to set up payers for the contract and indicates the reimbursement amount for the procedures. Contract exception A library that enables you to charge different fees based on the provider, location, and payer. Each additional fee is referred to as an exception to the contract and can be set up and maintained through the Contract library. After the exceptions are set up, you can assign a contract exception to providers at the provider, payer, or location level to apply the exce

Help Guide for NextGen® Enterprise PM 8

Patient Cost Estimation Workflow

The cost estimation feature enables you to use the information within the application to provide an insight into the various costs associated with the different types of care. A practice, running in a real-time system, has a valid NextGen® Eligibility Verification license and is able to communicate with the real-time server. When an eligibility transaction is run, the system receives real-time eligibility (271) transaction file as response. A practice, running in non-real-time system, does not have a valid NextGen® Eligibility Verification license and retrieves values from the local database. If you are the administrator, you must complete the following configurations in File Maintenance. Set up payers in the payer master Set up providers in the provider master Set up the pricing for service item (SIM) codes and associate SIM codes with CPT®4 codes in the SIM library You can configure the following as needed and are not mandatory. Set up sliding fee schedules in the sliding fee schedul

Help Guide for NextGen® Enterprise PM 8

Patient Cost Estimation Workflow

The cost estimation feature enables you to use the information within the application to provide an insight into the various costs associated with the different types of care. A practice, running in a real-time system, has a valid NextGen® Eligibility Verification license and is able to communicate with the real-time server. When an eligibility transaction is run, the system receives real-time eligibility (271) transaction file as response. A practice, running in non-real-time system, does not have a valid NextGen® Eligibility Verification license and retrieves values from the local database. If you are the administrator, you must complete the following configurations in File Maintenance. Set up payers in the payer master Set up providers in the provider master Set up the pricing for service item (SIM) codes and associate SIM codes with CPT®4 codes in the SIM library You can configure the following as needed and are not mandatory. Set up sliding fee schedules in the sliding fee schedul

Help Guide for NextGen® Enterprise PM 8

Retrieving Patient Benefits for Cost Estimation

Co-pay, deductible, and coinsurance are collectively referred to as patient benefits. Co-pay is the fixed amount the patient must pay for each visit, which is predetermined in the co-pay clause of the insurance policy. Deductible is the fixed amount a patient must pay each year before the insurance payer begins to cover the costs. After the patient pays the deductible amount as per the insurance plan, the payer starts to share the cost of the service. Coinsurance is the fixed cost for treating the covered services that the patient must bear after the deductible amount is paid. Non-covered charges are incurred on services that do not have insurance coverage. For a practice running in a real-time system, co-pay, deductible, coinsurance, and non-covered charges are retrieved from the real-time eligibility (271) transaction file. For a practice running in a non-real-time system, the patient benefits are retrieved as follows: The co-pay is retrieved from the patient's insurance information,

File Maintenance Help for NextGen® Enterprise 8

Contract Exception Maintenance Filter Criteria and Contract Exception Definitions

Enter the Filter Criteria using the table below. Filter Criteria Action/Required Information Enter the first number(s) of the CPT4 item you want to locate If the CPT4 column contains a lot of items, you can use this field to help you find a CPT4 code. Enter the first few numbers of the CPT4 code until the CPT4 item displays in the spreadsheet area of the window. Include Past CPT4 Items Select this check box to display all expired CPT4 items. Exception CPT4s only Select this check box to display CPT4 exceptions only. Enter the contract exception information for each CPT4 item listed using the table below: Filter Criteria Action/Required Information CPT4 and Date Range These fields display the CPT4 code information from the contract that you selected to create this exception. Allowed Enter the dollar amount allowed by the contract exception for the CPT4 code. Participating % Enter the percentage of the allowed fee that you expect to receive for services rendered by participating provider

Cost Estimation Data Sources

Recommendations

Retrieving Patient Benefits for Cost Estimation

Cost Estimation Data Sources

Patient Cost Estimation Workflow

Patient Cost Estimation Workflow

Retrieving Patient Benefits for Cost Estimation

Contract Exception Maintenance Filter Criteria and Contract Exception Definitions

Cost Estimation Data Sources

Retrieving Patient Benefits for Cost Estimation

Cost Estimation Data Sources

Patient Cost Estimation Workflow

Patient Cost Estimation Workflow

Retrieving Patient Benefits for Cost Estimation

Contract Exception Maintenance Filter Criteria and Contract Exception Definitions