Set Up Claim Edits for Encounter Rate Billing

Help Guide for NextGen® Enterprise PM 8

Add or Modify an Encounter Rate Billing Library

The Encounter Rate Billing library enables you to configure the billing process for payers who require a flat encounter rate. This library is used to configure the business rules applicable to a payer. The Encounter Rate Billing library provide the flexibility to set up multiple rate codes to accommodate the different billing requirements of individual payers. The appropriate library can then be attached to the payer. A SIM with the appropriate CPT4 code must be set up in the SIM library before you set up encounter rate billing. Note: When you copy an Encounter Rate Billing library, the SIM Configuration Hierarchy and the encounter rate information are also copied. To add or modify an Encounter Rate Billing library, do the following: Access File Maintenance. Select Libraries, and then Encounter Rate Billing. The Encounter Rate Billing List window opens. Do one of the following: To add a library, select Open Menu and select New. To modify a library, select the library from the list, and

Help Guide for NextGen® Enterprise PM 8

Set Up Payers for Encounter Rate Billing

Once the Encounter Rate Billing library has been created, it must be attached to the appropriate encounter rate payers. Attaching the Encounter Rate Billing library ensures that during the billing process in NextGen® Enterprise PM, the ER SIM code is inserted onto the encounter and the claim is configured correctly to meet the ER payer's specific requirements. Access File Maintenance. Select System Master Files, then PM, and then Payers. The Payers List window opens. From the list, select an ER payer, and then select Open Menu and select Open. The Modify Payer Information window opens. Select the Practice tab, and then select the Libraries sub-tab. In the Encounter Rate Library field, select the Encounter Rate Billing library for the payer. To save changes and close the window, select OK. Parent topic: Setting Up Encounter Rate Billing

Help Guide for NextGen® Enterprise PM 8

Add or Modify Transaction Codes for Encounter Rate Billing

Transaction codes can be used in the Encounter Rate Billing library to auto-adjust charges for payers using encounter rate billing. Having unique transaction codes assists in differentiating encounter rate adjustments from other types of adjustments on the UDS report. It also assists in either including or excluding encounter rate adjustments on financial reports in NextGen® Enterprise PM. If encounter rate billing is used for more than one payer, create a separate transaction code for each payer. For example: Medicare Enc Rate Adjustment Medicaid Enc Rate Adjustment To add or modify a transaction code for encounter rate billing, do the following: Access File Maintenance. Select System Master Files, then PM, and then Transaction Codes. The Transaction Codes List window opens. Do one of the following: To add a transaction code, select Open Menu and select New. To modify a transaction code, select the code from the list, and then select Open Menu and select Open. The Add/Modify Transacti

Help Guide for NextGen® Enterprise PM 8

Add or Modify Departments for Encounter Rate Billing

Creating unique encounter rate departments for use in the SIM library with Encounter Rate (ER) SIM codes can assist with reporting in NextGen® Enterprise PM. Financial reports can be filtered to either include or exclude ER codes by department, and reports can be sorted by department to group ER codes together. If encounter rate billing is used for more than one payer, create a separate department for each payer’s encounter rate SIM code(s). For example: Medicare Enc Rate Medicaid Enc Rate To add or modify a department for encounter rate billing, do the following: Access File Maintenance. Select Master Lists. The Master Lists List window opens. In the Master List field, select Departments. The Departments List appears. Do one of the following: To add a department, select Open Menu and select New. To modify a department, select the department from the list, and then select Open Menu and select Open. The Add/Modify Department Information window opens. Add Department Information In the De

Help Guide for NextGen® Enterprise PM 8

Set Up Claim Edits for Encounter Rate Billing

When an encounter is billed in NextGen® Enterprise PM, auto-adjustments are applied to the original charges based on parameters defined in the Encounter Rate Billing library. For most Medicaid (non-Medi-Cal) payers, the first charge on the encounter is auto-adjusted to a balance equal to Medicaid's encounter rate, and all other charges are auto-adjusted to a balance of $0.00. All charges, including the $0.00 balance charges, must appear on the claim for Medicaid. To accomplish this, claim edit #97 must be deactivated in the Claim Edits library used for Medicaid. Note: A default Medicaid Claim Edits library comes pre-installed. It is suggested that Claim Edit #97 be deactivated in this library, and then attach the library to Medicaid (non-Medi-Cal) payers. Access File Maintenance. Select Libraries, and then Claim Edits. The Claim Edits List window opens. From the list, select a library and then select Open Menu and select Open. The Claim Edit Library Maintenance window opens. Select the

Help Guide for NextGen® Enterprise PM 8

Setting Up Encounter Rate Billing

Encounter rate billing in NextGen® Enterprise PM involves the following setup in System Administrator and File Maintenance: Security Access Rights Enterprise Preferences Practice Preferences CPT4 Codes Revenue Codes Departments Service Items Library Claim Edits Library Transaction Codes Encounter Rate Billing Library Payers Set Up Security Access Rights for Encounter Rate Billing Set Up Enterprise Preferences for Encounter Rate Billing Practice Preferences for Encounter Rate Billing Add or Modify CPT4 Codes for Encounter Rate Billing Add or Modify Revenue Codes for Encounter Rate Billing Add or Modify Departments for Encounter Rate Billing Add or Modify SIM Codes for Encounter Rate Billing Set Up Claim Edits for Encounter Rate Billing Add or Modify Transaction Codes for Encounter Rate Billing Add or Modify an Encounter Rate Billing Library Set Up Payers for Encounter Rate Billing Parent topic: Encounter Rate Billing

Set Up Claim Edits for Encounter Rate Billing

Recommendations

Add or Modify an Encounter Rate Billing Library

Set Up Payers for Encounter Rate Billing

Add or Modify Transaction Codes for Encounter Rate Billing

Add or Modify Departments for Encounter Rate Billing

Set Up Claim Edits for Encounter Rate Billing

Setting Up Encounter Rate Billing

Set Up Claim Edits for Encounter Rate Billing

Add or Modify an Encounter Rate Billing Library

Set Up Payers for Encounter Rate Billing

Add or Modify Transaction Codes for Encounter Rate Billing

Add or Modify Departments for Encounter Rate Billing

Set Up Claim Edits for Encounter Rate Billing

Setting Up Encounter Rate Billing