COB Balancing Using the 5010 Format

Determined By	Calculation
Payer	The Allowed Amount uses the prior payer's payment information coupled with adjustment information in the CAS segments in this loop. The Allowed Amount = the prior payer payment + the sum total of all patient responsible adjustment amounts (in loop 2320) The patient responsible adjustments are identified by use of the Category Code PR in CAS01.
Provider	The Allowed Amount uses the prior payer's payment information coupled with the Remaining Patient Liability AMT segments. The Allowed Amount = the prior payer payment + the Remaining Patient Liability AMT amount

Help Guide for NextGen® Enterprise PM 8

Set Up a COB Imbalance Warning

You can setup a practice preference to issue a warning when the COB allowed or billed amount is out of balance. On the Admin menu and select Preferences and then Practice. The Practice Preferences window opens. Select Transactions from the Preference List. In the COB Windows Options section of the window, enable one or more of the following check boxes: Warn on COB imbalance with allowed amount Warn on COB imbalance with billed amount After you enable one of the check boxes, and close the Coordination of Benefits Information window, a balance check is performed on the COB information. If the information does not balance, then one or both of the following warning messages appear if the allowed amount or billed amount is out of balance: Paid amount and patient responsible amounts do not equal allowed amount. Do you want to continue? All payments and adjustments do not equal billed amount. Do you want to continue? Parent topic: 277 File

Help Guide for NextGen® Enterprise PM 8

Enter the Allowed Amount in the COB Information Window

If the primary payment allowed amount was posted incorrectly or left blank, you cannot edit the amount on the Payment Entry window, but you can correct it using the following procedure: On the Payment Entry window, select the COB button. The Coordination of Benefits Information window appears. Enter the correct amount in the Allowed column. Note: The allowed amount is required in the secondary file to balance, so if your COB does not list an allowed amount, you must enter the charge amount as the allowed amount. Select OK. The amount is pulled into the 837 file for secondary electronic claims processing. Parent topic: Coordination of Benefits Electronic and Manual Processing

File Maintenance Help for NextGen® Enterprise 8

COB Electronic Claims Sub-Tab

The options on the COB Electronic Claims tab work only for electronic secondary claims and accommodate 837 COB requirements. CAUTION: These options should never be enabled unless the payer requires them. Claim rejections can occur if these segments are present and the payer does not want them. Field Description Populate 2400 CN1 contractual adjustment segment Select this option to add a service line CN1 segment (2400). This amount is also referred to as the OTAF (obligated to accept in full) amount. If this option is enabled and a service line contractual adjustment exists (CAS*CO), then the allowed amount is added as the 2400 CN1 amount. The presence of the CAS*CO segment causes the CN1 segment to create mimicking the allowed/approved amount in the AMT*AAE segment. Enable COB information popup in payment entry Select this option so that during transaction entry the Coordination of Benefits Information window automatically displays when the user tabs out of the Reason field for the las

Help Guide for NextGen® Enterprise PM 8

COB Electronic Claims Sub-Tab

The options on the COB Electronic Claims tab work only for electronic secondary claims and accommodate 837 COB requirements. CAUTION: These options should never be enabled unless the payer requires them. Claim rejections can occur if these segments are present and the payer does not want them. Field Description Populate 2400 CN1 contractual adjustment segment Select this option to add a service line CN1 segment (2400). This amount is also referred to as the OTAF (obligated to accept in full) amount. If this option is enabled and a service line contractual adjustment exists (CAS*CO), then the allowed amount is added as the 2400 CN1 amount. The presence of the CAS*CO segment causes the CN1 segment to create mimicking the allowed/approved amount in the AMT*AAE segment. Enable COB information popup in payment entry Select this option so that during transaction entry the Coordination of Benefits Information window automatically displays when the user tabs out of the Reason field for the las

File Maintenance Help for NextGen® Enterprise 8

Transactions Practice Preferences Descriptions

The following table describes the fields located in the Transaction Practice Preferences. Default Transaction Spreading Field Description Transaction Source Select Patient or Third Party and then select one of the FIFO or weighted options. Note: Users can also spread using the FIFO methods by right-clicking on thePayment Entry window. First In/ First Out – (FIFO) applies payments to the oldest line items, until the payment is disbursed. First In/ First Out - Pat Resp Date – Select Patient and then select this option to spread payment and adjustment transactions to detail line items by the earliest patient responsibility date. Weighted distribution – applies a weighted percentage to all line items. Reason Codes Options Field Description Default Reason Code Library Select a default reason code library, which is used for all payers who do not have a specific library attached to them at the payer master level. You can create and modify reason code libraries in the Libraries section of File

Help Guide for NextGen® Enterprise PM 8

Posting Logic for Bundled Payment to Multiple Charges

When you bill individual unit charge lines for the same CPT® code and the payer sends a single payment for all of those charges in the Electronic Remittance Advice (ERA) file, you can use the Post Bundled Payment to Multiple Charges option to distribute the transaction amounts. Based on the quantity, the Allowed, Payment, and Adjustment amounts are distributed equally across all charge lines. If the bundled transaction amount does not divide equally across the charge lines, the transaction is not posted and a message appears stating that the bundled payment did not get distributed equally Bundled Payment does not distribute equally in the ERA Import report. The patient-responsible amounts (PR1 Deductible, PR2 Co-Insurance, PR3 Co-pay) are distributed for only reporting purposes and Cordination of Benefits (COB) balancing. The patient-responsible amounts are distributed using weighted distribution logic. When you configure the Remittance Profile library to Only when deductible (PR1) exi

COB Balancing Using the 5010 Format

Recommendations

Set Up a COB Imbalance Warning

Enter the Allowed Amount in the COB Information Window

COB Electronic Claims Sub-Tab

COB Electronic Claims Sub-Tab

Transactions Practice Preferences Descriptions

Posting Logic for Bundled Payment to Multiple Charges

Set Up a COB Imbalance Warning

Enter the Allowed Amount in the COB Information Window

COB Electronic Claims Sub-Tab

COB Electronic Claims Sub-Tab

Transactions Practice Preferences Descriptions

Posting Logic for Bundled Payment to Multiple Charges