If the practice is running in a real-time system, the system fetches the co-pay amount in the real-time eligibility (271) transaction file. If multiple co-pay amounts are found in the eligibility verification response, they are listed in the Estimate Patient Cost window.
If your practice is running in a non-real-time system, the co-pay amount is obtained from the Insurance Maintenance window, Contract Exception Maintenance window, or Contract Library Maintenance window, based on a particular hierarchy system.
Co-Pay from Insurance Information
Based on the co-pay settings in the Payers master file in File Maintenance, co-pay amounts appear on the Insurance Maintenance window in NextGen® Enterprise PM.
Your administrator must enable multiple co-pays by opening the Enterprise Preferences window, the General tab, and selecting the Enable multiple co-pays check box.
On the Insurance Maintenance window, the co-pay amounts for cost estimation are as follows:
- Speciality co-pay information, such as specialty name and the co-pay amount, appears on the Insurance Maintenance window. You can add more than one specialty for a payer.
If you are an administrator, you must specify the provider's specialty and payer co-pay for specific specialities in File Maintenance:
- A provider can have two specialty codes that can be specified in the Providers master file. When you add or modify provider information, you can specify Speciality Code1 and Speciality Code2 in the System tab of the Add Provider Information or Modify Provider Information window.
- A rendering provider in the current practice can have one specialty that can be specified in the Providers master file. When you add or modify provider information, you can specify the Speciality in the Practice tab of the Add Provider Information or Modify Provider Information window.
Note: The rendering provider's specialty in the Practice tab takes preference over the specialty codes in the System tab.
- The co-pay information created in the Payers master file becomes the default for all insurances. When you add or modify co-pay information for a payer, you can select the specialties for the co-pay and set a co-pay amount. If any of the specialties on the co-pay matches the specialty of the rendering provider on the encounter, the amount set as the default co-pay amount in the Add Payer Co-Pay Information window becomes the default amount used as encounter specialty co-pay in the Insurance Maintenance window.
The co-pay amount for each service line item in the Estimate Patient Cost window is derived based on the following preferences:
- If the rendering provider's specialty matches with the payer co-pay, the co-pay amount is considered according to the rendering provider's co-pay.
- If the provider's specialty code1 matches with the payer co-pay, the co-pay amount is considered according to specialty code1.
- If the provider's specialty code2 matches with the payer co-pay, the co-pay amount is considered according to specialty code2.
- The amount in Enc Co-payment defines the encounter-level co-pay.
Note: The Enc Co-Payment field is available only if the Enable encounter payer copay option is selected in Chart practice preferences
- The amount in Co-Pay for [Patient Name] defines the insurance maintenance override co-pay.
Note: The Co-Pay for [Patient Name] field is available only if the Display override policy number and co-pay option is selected in the Defaults-2 tab of the Payers master file.
- The amount in Co-Payment in the Practice Level section defines insurance maintenance practice-level co-pay or insurance maintenance enterprise-level co-pay.
Note: The settings in the
Chart preferences determine whether the co-pay is practice-level or enterprise-level.
- If the Enable practice payer specific information option is selected, the co-pay amount is practice level.
- If the Enable practice payer specific information option is not selected, the co-pay amount is enterprise-level.
The co-pay is retrieved as percentage for cost estimation if you select Co-Pay Type as Percent in the Insurance Maintenance window. However, if co-pay percentage is retrieved, the co-pay amount is calculated as co-pay percentage of allowed amount.
Co-Pay from Contract
The contract-level co-pay amount is derived from the contract exception or contract library. The co-pay amount in the contract exception takes precedence over that in the contract library.
If you are an administrator, you must configure the following settings in File Maintenance:
- You must select the desired managed care contract to associate with the payer in the payer master file.
From the , open Add Payer Information or Modify Payer Informationwindow for a payer and select a contract from Managed Care Contract.
- You must select contract exception for the contract provider in the provider master file.
From the , open Practice tab and then Libraries sub-tab. Open the Modify Provider Practice Payer window and select the desired exception from Contract Exception.
- You can set up the fee schedule for CPT®4 codes in the contract exception or contract library.
In the
Contract Library Maintenance window or
Contract Exception Maintenance window, you can select the
field under
Apply Co-Pay to indicate that the CPT®4 code requires a co-pay and enter the co-pay amount.
Note: If the Apply Co-Pay field is not selected, the co-pay amount appears blank on the Estimate Patient Cost window.
- You can retrieve the percentage value of co-pay for cost estimation by setting the payer master file. In File Maintenance, you can open Master Files , select Systemand then select Payers. For a new payer, you can open the Add Payer Information window or select a payer and open the Modify Payer Information window. You can select the Copay Percent Calc check box.
Note:
- To obtain co-pay from the contract library, the contract must be associated with the payer and provider.
- To obtain co-pay from the contract exception, the provider, service location, and the contract payer set in the contract exception must match your selections in the Estimate Patient Cost window.
- For a service item, co-pay and coinsurance amounts cannot be retrieved together from contract exception or contract library.
When co-pay is retrieved from the contract library for estimating the cost, it can be retrieved as percentage or amount. When co-pay comes from the
Fee Schedule tab of the
Contract Library Maintenance window, the co-pay amount is calculated based on the value in
Co-Pay Origin in the
Contract Library Maintenance window's
General tab.
- If co-pay origin is <none> or Allowed, co-pay amount is calculated as co-pay percentage of allowed amount given in the Fee Schedule tab.
- If co-pay origin is Reimbursement, co-pay is calculated as co-pay percentage of provider reimbursement amount given in the Fee Schedule tab.
The co-pay amount appears blank on the
Estimate Patient Cost window if one of the following conditions is true:
- Co-pay has not been applied to the CPT®4 code in the contract exception or contract library.
- Provider reimbursement is less than 100% or blank.
- Coinsurance amount is displayed on the Estimate Patient Cost window.
Note: After estimating the cost on the Estimate Patient Cost window, the co-pay amount in the estimate is not updated back to the contract exception or contract library.
Co-Pay Hierarchy
The co-pay amount for estimation is derived using the following hierarchy:
- Insurance maintenance specialty co-pay
- Contract-level co-pay
- Encounter-level co-pay
- Insurance maintenance override co-pay
- Insurance maintenance practice-level co-pay
- Insurance maintenance enterprise-level co-pay
In a real-time system, co-pay can be found in the real-time eligibility (271) transaction file. If the co-pay amount is not found, the system follows the co-pay hierarchy to fetch it for cost estimation.
The co-pay hierarchy workflow in a non-real-time system is as follows:
- The system looks for insurance maintenance specialty co-pay in the insurance information.
- If insurance maintenance specialty co-pay is not found, the system continues with the next step in the co-pay hierarchy and looks for co-pay in the contract exception or contract library.
- If contract-level co-pay is not found, the system continues with the next step in the co-pay hierarchy and looks for encounter-level co-pay.
- If encounter co-pay is not found, the system continues with the next step in the co-pay hierarchy and looks for insurance maintenance override co-pay.
- If the insurance maintenance override co-pay is blank, the system continues with the next step in the co-pay hierarchy and looks for insurance maintenance practice-level co-pay.
- If insurance maintenance practice-level co-pay is blank, the system continues with the next step in the co-pay hierarchy and looks for insurance maintenance enterprise-level co-pay.
- If insurance maintenance enterprise-level co-pay is blank, the co-pay field is blank and co-pay is considered zero dollars for calculating the estimation.
