Determining Crossover Claims

Help Guide for NextGen® Enterprise PM 8

Reading the ERA Import Posting Report

After you have completed the ERA Posting process, the ERA Import Posting report generates. Overall, the report is a complete audit of the ERA 835 file and is grouped by unsuccessful and successful entries. NextGen® Enterprise PM does not, however, report provider level adjustments. The report is sorted by practice with the ERA payments that did not post successfully listed first, followed by all the ERA payments that posted successfully. An ERA message displays in the Description column of the report next to each line item as an indicator for why the ERA claim payment did or did not post against the encounter information. Each of these messages applies to ANSI file formats. The transaction level Reason Codes that are distributed to service lines display on the report, along with their descriptions. Note: The ERA Import Posting report detects and rejects an ERA transaction with a denial reason code and total transaction amount that is not $0.00. Resolving Encounter-Related ERA Errors On

Help Guide for NextGen® Enterprise PM 8

Determining Crossover Claims

When ERA files are imported, you can determine from the Complimentary Insurance Flag field if the claim has been handled as a crossover, even if the payer is not set up to be a crossover. A value of NM1*TT in this field indicates that the insurance that was billed, automatically forwarded the balance of the claim to the secondary insurance, regardless of the crossover flag in the application. By using the Complimentary Insurance Flag, you can make sure that the Medicare payers that automatically forward remaining balances to a secondary insurance are correctly handled in the application. When transaction detail records are created from the ERA process for crossover claims, the Status is set to Forwarded to and the Charge Rebill Indicator is set to N, so the secondary payer is not flagged for billing. Parent topic: Posting an Electronic Remittance

Help Guide for NextGen® Enterprise PM 8

Posting an Electronic Remittance

This section provides information about the process of posting an electronic remittance. When posting the ERA, the system compares the ERA payment information for each claim in the file against the encounter information in your system that the claim was originally created for. In order for the ERA payments for each claim to post successfully, the ERA payment information for a claim must match the encounter information the ERA is posting against. If there is a discrepancy between the ERA information and the encounter information, the ERA payment for that claim does not post and an error message displays on the ERA Import Posting report. In addition, if an ERA payment is posting against multiple line items in an encounter, all the line items must be error-free for the ERA payment to post successfully. The ERA process only calculates and posts adjustments for encounter primary and secondary payers. If the primary ERA pays a charge off, it is settled to the secondary and is included on the

Help Guide for NextGen® Enterprise PM 8

Additional Information

If a patient has a payer with the ERA – Create Zero Dollar Total Balance Claims to Selected Subsequent Payer(s) check box enabled, whether the payer is primary or secondary, and the patient’s next payer is one of the selected subsequent payers, then when an ERA 835 file is processed for that payer and an adjustment is posted from the CAS segment, the following occurs: Transaction Detail Status for charge line items associated with the claim default to Settled move to subsequent payer. Charge line items associated with the claim are flagged for rebill. The encounter status changes from Billed to Rebill. When the ERA – Create Zero Dollar Total Balance Claims to Selected Subsequent Payer(s) check box is not enabled for the payer and an adjustment reason code is defined with a Transaction Detail Status of Settled moved to secondary or Settled moved to tertiary, the following occurs when an ERA 835 file with that adjustment reason code is processed: Transaction Detail Status for charge line

Help Guide for NextGen® Enterprise PM 8

Additional Information

If a patient has a payer with the ERA – Create Zero Dollar Total Balance Claims to Selected Subsequent Payer(s) check box enabled, whether the payer is primary or secondary, and the patient’s next payer is one of the selected subsequent payers, then when an ERA 835 file is processed for that payer and an adjustment is posted from the CAS segment, the following occurs: Transaction Detail Status for charge line items associated with the claim default to Settled move to subsequent payer. Charge line items associated with the claim are flagged for rebill. The encounter status changes from Billed to Rebill. When the ERA – Create Zero Dollar Total Balance Claims to Selected Subsequent Payer(s) check box is not enabled for the payer and an adjustment reason code is defined with a Transaction Detail Status of Settled moved to secondary or Settled moved to tertiary, the following occurs when an ERA 835 file with that adjustment reason code is processed: Transaction Detail Status for charge line

Help Guide for NextGen® Enterprise PM 8

Posting an Electronic Remittance

This section provides information about the process of posting an electronic remittance. When posting the ERA, the system compares the ERA payment information for each claim in the file against the encounter information in your system that the claim was originally created for. In order for the ERA payments for each claim to post successfully, the ERA payment information for a claim must match the encounter information the ERA is posting against. If there is a discrepancy between the ERA information and the encounter information, the ERA payment for that claim does not post and an error message displays on the ERA Import Posting report. In addition, if an ERA payment is posting against multiple line items in an encounter, all the line items must be error-free for the ERA payment to post successfully. The ERA process only calculates and posts adjustments for encounter primary and secondary payers. If the primary ERA pays a charge off, it is settled to the secondary and is included on the

Determining Crossover Claims

Recommendations

Reading the ERA Import Posting Report

Determining Crossover Claims

Posting an Electronic Remittance

Additional Information

Additional Information

Posting an Electronic Remittance

Determining Crossover Claims

Reading the ERA Import Posting Report

Determining Crossover Claims

Posting an Electronic Remittance

Additional Information

Additional Information

Posting an Electronic Remittance