Set Up Medical Necessity Other than Medicare for Payers

NextGen® Enterprise EHR Help

Set Up the Medical Necessity Location

The Location field in the NextGen® Medical Necessity Check setup is not a practice location, it is a location for Medical Necessity related to Medicare coverage. Open File Maintenance and select System > Locations. Select the list or enter your location name, and then select Open Menu to open your location. Select Order module tab. In the Medical Necessity section, select B from the Part A or Part B list and the Location, for example Pennsylvania. Note: The NextGen® Medical Necessity Check only runs against those orders that have Medicare Part B associated with them. Select OK to save these values for the selected practice. 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

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

Medical Necessity Setup

You must set up the NextGen® Medical Necessity Check to determine if Medicare will pay for a test when selecting a diagnosis for an order and run it when you place a test order. If Medicare or other insurance does not cover the costs of the test, you can print an Advanced Beneficiary Notice (ABN) and record the patients' decision about how to handle test codes. If an order does not contain Medicare or other insurance then you can't run NextGen® Medical Necessity Check as this follows the Medicare guidelines. Note: You need to obtain a license to run NextGen® Medical Necessity Check. To set up the NextGen® Medical Necessity Check locations, do the following: Access and download the NextGen® Medical Necessity Check update package from the NextGen Healthcare Success Community. This package populates the Locations (and associated data) in the Orders Module tab. Set up the appropriate NextGen® Medical Necessity Check encounter level insurance for the appropriate location. For more informati

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

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

Set Up Medical Necessity Other than Medicare for Payers

Recommendations

Set Up the Medical Necessity Location

Set Up Medical Necessity to Run Automatically

Skip the Medical Necessity Check if Test has no CPT4 Code

Medical Necessity Setup

Checking Medical Necessity for a Test

Select ABN Option for Failed Medical Necessity Check

Set Up the Medical Necessity Location

Set Up Medical Necessity to Run Automatically

Skip the Medical Necessity Check if Test has no CPT4 Code

Medical Necessity Setup

Checking Medical Necessity for a Test

Select ABN Option for Failed Medical Necessity Check