Medical Necessity Setup

NextGen® Enterprise EHR Help

Set Up Medical Necessity Other than Medicare for Payers

Starting with Version 5.8, you can run the NextGen® Medical Necessity Check for payers other than Medicare. These payers, however, must follow the Medicare guidelines. You must set up each payer individually. Open File Maintenance. Select System > Payer. Select your payer, and select Open Menu to access your payer. Select the Order Module tab. To indicate that the NextGen® Medical Necessity Check should be run for this payer, select Follows Medicare rules for Medical Necessity Checking. To access an ABN report, select the folder and then select the ABN report path or you can enter the ABN report path, and select the ABN Crystal Report. Note: The Advanced Beneficiary Notice (ABN) report has been updated to be in compliance with the Centers for Medicare and Medicaid Services (CMS) regulations. For more information, download the latest Reports User Guide forNextGen®Enterprise EHR. Select OK. Parent topic: Medical Necessity Setup

NextGen® Enterprise EHR Help

Obtain the ABN Report and Verify Cost Coverage When a NextGen® Medical Necessity Check Fail

When you run the medical necessity check for a patient with Medicare or another insurance (which follows Medicare guidelines), if the test fails, a notice displays. A red X is returned when you select Check Medical Necessity for an order. Note: If you receive a Cannot Confirm message, Medicare coverage for the selected tests cannot be determined. This message is not the same as a failure. Run the NextGen® Medical Necessity Check again to confirm coverage. If the NextGen® Medical Necessity Check fails, do the following: In the Select Medical Necessity Failure Reason window, select the reason for the failure. To print an Advanced Beneficiary Notice (ABN) to give to the patient, select Print ABN. The ABN includes the reason for the failure. To preview the ABN before you print it, select Preview ABN. Contact the patient to determine how the patient would like to pay for the services. Document the patient's payment option in the ABN Options section on the Assign Diagnosis to Select Tests pa

NextGen® Enterprise EHR Help

Checking Medical Necessity for a Test

To determine if Medicare or another insurance (which follows Medicare guidelines) covers the cost of a test, you can run the NextGen® Medical Necessity Check. You can set up the Medical Necessity Check in File Maintenance to run automatically when you save an order or you can run it manually. Note: To use the NextGen® Medical Necessity Check when selecting tests, you must first set it up in File Maintenance. For more information about setting up Medical Necessity, go to the NextGen Healthcare Success Community and download the Orders Module Setup Guide for NextGen® Enterprise. To run it manually, select the Check Medical Necessity in the Assign Diagnosis to Selected Tests panel. Obtain the ABN Report and Verify Cost Coverage When a NextGen Medical Necessity Check Fail Parent topic: Assign Diagnosis to Selected Tests Panel

NextGen® Enterprise EHR Help

Skip the Medical Necessity Check if Test has no CPT4 Code

You can set up NextGen® Medical Necessity Check to skip those tests that do not have a CPT4 code assigned. NextGen® Medical Necessity Check will check tests with CPT4 codes and will not produce errors if a test with no CPT4 code is found. Select File Maintenance > System > Practices. Select the list or enter your location name and select Open Menu to open your practice. Select Preferences. In the Practice Preferences window, select Order module > Lab/Rad tab. To indicate that the Medical Necessity Check should not run when a test does not contain a CPT4 code, select Skip Medical Necessity Check if no CPT4 code. Select OK to save this preference. Select OK to exit the Modify Practice Information window. Parent topic: Medical Necessity Setup

NextGen® Enterprise EHR Help

Set Up Medical Necessity to Run Automatically

You can choose to set up NextGen® Medical Necessity Check to run automatically when you save an order. Select File Maintenance > System > Practices. Select the list or enter your location name and select Open Menu to open your practice. Select Preferences. In the Practice Preferences window, select Order Module > Lab/Rad tab. To automatically run the NextGen® Medical Necessity Check when you save an order, select Run Medical Necessity Check when order is saved. Select OK to save this preference. Select OK to exit the Modify Practice Information window. Parent topic: Medical Necessity Setup

NextGen® Enterprise EHR Help

Select ABN Option for Failed Medical Necessity Check

Before you begin Ensure that you have the required license for Medical Necessity check. Ensure that you have configured medical necessity check in File Maintenance. Ensure that you have selected the insurance information for the patient in the All tab. Note: Computerized Physician Order Entry (CPOE) derives the insurance settings from the Practice Preferences configurations. For more information on Practice Preferences in File Maintenance, go to NextGen Healthcare Success Community and download the latest File Maintenance Preferences Guide for NextGen® Enterprise. For a test that does not meet the medical necessity criteria for insurance reimbursement, the patient can consent to financial responsibility by signing the Advance Beneficiary Notice (ABN). You can print the ABN for the patient to read and sign and record the patient's ABN status. Open CPOE. Select an order item. Assign a diagnosis to the selected order item. Select the Laboratory or Diagnostic tab and check if the order ite

Medical Necessity Setup

Recommendations

Set Up Medical Necessity Other than Medicare for Payers

Obtain the ABN Report and Verify Cost Coverage When a NextGen® Medical Necessity Check Fail

Checking Medical Necessity for a Test

Skip the Medical Necessity Check if Test has no CPT4 Code

Set Up Medical Necessity to Run Automatically

Select ABN Option for Failed Medical Necessity Check

Set Up Medical Necessity Other than Medicare for Payers

Obtain the ABN Report and Verify Cost Coverage When a NextGen® Medical Necessity Check Fail

Checking Medical Necessity for a Test

Skip the Medical Necessity Check if Test has no CPT4 Code

Set Up Medical Necessity to Run Automatically

Select ABN Option for Failed Medical Necessity Check