Auto-Balancing the CAS Segment on Secondary/Tertiary Claims

Help Guide for NextGen® Enterprise PM 8

Auto-Balancing the CAS Segment on Secondary/Tertiary Claims

When an encounter rate charge is added during the billing process for a non-primary ER payer, the prior payer's billed amount does not match and the secondary/tertiary electronic claim is thrown out of balance. This causes the secondary/tertiary claim to be rejected by the clearinghouse or payer. To address this situation, the system can automatically insert a value in the CAS segment on the claim. The What Reason code is sent in the CAS segment to auto balance the claim? option is available on the Claims tab of the Encounter Rate Billing library, under the Secondary Electronic Claims and Tertiary Electronic Claims sections. To auto-balance the variance amount on COB claims, select a code from the HIPAA X12 Standard Reason Codes library. The selected reason code and the variance amount populate the CAS segment on COB electronic claims. This keeps the COB claim in balance and prevents the need for manual manipulation. Note: This option is available only if the Do you send the ER SIM as

File Maintenance Help for NextGen® Enterprise 8

Set Up the COB Claims Tab

The COB Claims tab on the Encounter Rate Billing Library Maintenance window defines whether or not payers that may be subsequent to an encounter rate payer require the ER SIM code on their secondary/tertiary claims. For example, Medicare requires an Encounter Rate SIM code, or pay code, on qualified FQHC claims. Medicare then pays on that ER SIM. To create a balanced electronic secondary claim, the Medicare ER SIM must appear on the secondary claim with the appropriate CAS segments. In the case where the primary is an encounter rate payer and the secondary is not, but the secondary needs to see the ER SIM from the primary payer on the claim, the setup can be either of the following: Setup the Encounter Rate Library for the primary payer to insert the ER SIM as a charge, so the charge can be flagged to bill to the next payer. Setup the Encounter Rate Library for the primary payer to insert the ER SIM on Encounter Maintenance, and then setup an ER Library for the secondary payer to inser

Help Guide for NextGen® Enterprise PM 8

Set Up the COB Claims Tab

The COB Claims tab on the Encounter Rate Billing Library Maintenance window defines whether or not payers that may be subsequent to an encounter rate payer require the ER SIM code on their secondary/tertiary claims. For example, Medicare requires an Encounter Rate SIM code, or pay code, on qualified FQHC claims. Medicare then pays on that ER SIM. To create a balanced electronic secondary claim, the Medicare ER SIM must appear on the secondary claim with the appropriate CAS segments. In the case where the primary is an encounter rate payer and the secondary is not, but the secondary needs to see the ER SIM from the primary payer on the claim, the setup can be either of the following: Setup the Encounter Rate Library for the primary payer to insert the ER SIM as a charge, so the charge can be flagged to bill to the next payer. Setup the Encounter Rate Library for the primary payer to insert the ER SIM on Encounter Maintenance, and then setup an ER Library for the secondary payer to inser

Help Guide for NextGen® Enterprise PM 8

Coordination of Benefits Electronic and Manual Processing

You can view information on all the payers for EDI claims in the Coordination of Benefits Information (COB) window. The Coordination of Benefits Information window provides information on all payers for EDI claims. This includes primary, secondary, and tertiary payers for 837I, 837P, and 837D claims. A summary of all COB activity by charge lines on an encounter for all previous transactions will display on the Coordination of Benefits Information window. When viewing COB1, COB2, COB 3, or All Payer data fields are editable by transaction line. ERA File When the ERA file contains a CAS segment with a charge line that has two identical reason codes, one CAS segment is created for the two identical reason codes in the 837 file. The reason codes are combined and display on a single line in the 837 file. Example: The COB window contains CO45 $50 and CO45 $25 and a PR2 on a single service line, the CAS segment will create CAS*CO*45*75 in the 837 file to represent the CO45 amounts and continu

Help Guide for NextGen® Enterprise PM 8

Coordination of Benefits Electronic and Manual Processing

You can view information on all the payers for EDI claims in the Coordination of Benefits Information (COB) window. The Coordination of Benefits Information window provides information on all payers for EDI claims. This includes primary, secondary, and tertiary payers for 837I, 837P, and 837D claims. A summary of all COB activity by charge lines on an encounter for all previous transactions will display on the Coordination of Benefits Information window. When viewing COB1, COB2, COB 3, or All Payer data fields are editable by transaction line. ERA File When the ERA file contains a CAS segment with a charge line that has two identical reason codes, one CAS segment is created for the two identical reason codes in the 837 file. The reason codes are combined and display on a single line in the 837 file. Example: The COB window contains CO45 $50 and CO45 $25 and a PR2 on a single service line, the CAS segment will create CAS*CO*45*75 in the 837 file to represent the CO45 amounts and continu

Help Guide for NextGen® Enterprise PM 8

Set Up the Secondary and Tertiary Encounter Rate Tabs

The Secondary Encounter Rate and Tertiary Encounter Rate tabs on the Encounter Rate Billing Library Maintenance window contain billing rules that apply when the ER payer is the secondary or tertiary payer on the encounter. Open the Encounter Rate Billing library. The Encounter Rate Billing Library Maintenance window opens. Select the Secondary Encounter Rate or Tertiary Encounter Rate tab. Select the Secondary Calculations when Medicare is the primary payer or Tertiary Calculations when Medicare is the primary payer settings for calculating the encounter rate when Medicare is the primary payer. The options are: Encounter Rate amount is equal to the: Select one of the following options to determine the calculation for the encounter rate of the secondary or tertiary payer when Medicare is the primary insurance. Encounter Rate minus Medicare allowed Medicare allowed minus Medicare paid Encounter Rate amount minus Medicare paid Medicare paid minus Encounter Rate amount Encounter Rate amoun

Auto-Balancing the CAS Segment on Secondary/Tertiary Claims

Recommendations

Auto-Balancing the CAS Segment on Secondary/Tertiary Claims

Set Up the COB Claims Tab

Set Up the COB Claims Tab

Coordination of Benefits Electronic and Manual Processing

Coordination of Benefits Electronic and Manual Processing

Set Up the Secondary and Tertiary Encounter Rate Tabs

Auto-Balancing the CAS Segment on Secondary/Tertiary Claims

Auto-Balancing the CAS Segment on Secondary/Tertiary Claims

Set Up the COB Claims Tab

Set Up the COB Claims Tab

Coordination of Benefits Electronic and Manual Processing

Coordination of Benefits Electronic and Manual Processing

Set Up the Secondary and Tertiary Encounter Rate Tabs