Rules for Claims Consolidation in a Hold Status

Help Guide for NextGen® Enterprise PM 8

Create HOLD Claims for CSC Candidate Encounters

During the normal billing process, CSC Candidate Encounters are identified. These encounters must meet the following rules: Multiple encounters for the same patient, on the same day, week, month, or case. Each practice can setup the time-frame for encounter consolidation in the Consolidated Services Claim library. Encounters are attached to the same payer. Meet all claim rules defined in the Consolidated Services Claim library. Hold Status Parent topic: Consolidated Service Claims

Help Guide for NextGen® Enterprise PM 8

Consolidated Services Claim

The claims services consolidation process is activated from the Claim Request Lookup window. The user will select the applicable claims to consolidate and then the application automatically consolidates the candidate claims into a Consolidated Services Claim (CSC). This process produces a Consolidated Services Claim report and alerts the user to any further actions that need to be taken before a CSC claim can be created. Note: The Consolidate Same Day Claims option is active when a CSC library is selected on the Practice Preferences Library window. Only claims with a Hold status can be consolidated by the CSC process. Parent topic: Consolidated Service Claims

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

Automatic Identification of CSC Candidate Encounters

CSC candidate encounters are identified during the billing process and meet the following criteria: All services for a patient in a calendar. All services provided to a patient in a specific time-period that are submitted on a single claim. The time period is defined by the practice and can be daily, weekly, monthly, or on a case basis. The encounters meet the rules applied in the Consolidated Service Claim library for combining form types and encounter rate options. Note: Hold Claim Status: The Hold status is applied to all claims that meet the criteria for CSC candidate encounters. Non-coordinated or Non-covered Service SIMs: Encounters with SIMs for non-coordinated or non-covered services DO NOT qualify as CSC Candidate encounters. Guidelines for Running the CSC Process Parent topic: Consolidated Service Claims

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

Rules for Claims Consolidation in a Hold Status

Recommendations

Create HOLD Claims for CSC Candidate Encounters

Consolidated Services Claim

CSC Terms

Automatic Identification of CSC Candidate Encounters

Exempting CSC Encounters

Consolidated Services Claim Library

Rules for Claims Consolidation in a Hold Status

Create HOLD Claims for CSC Candidate Encounters

Consolidated Services Claim

CSC Terms

Automatic Identification of CSC Candidate Encounters

Exempting CSC Encounters

Consolidated Services Claim Library