The eligibility verification functionality in NextGen allows you to
- verify patient benifit and the benifit coverage.
- referrals from primary physician to a specialist
- check on a claim status with a payer
- submit authorization requests
managed patient care involves referrals from a primary care provider to an authorized specialist. Referral history allows you to view all the previous referrals for a given patient
authorization involvess requests for approval frm payers for the services to be rendered
verify patient benifit and the benifit coverage. Line level and claim level authorizations and referrals for primary, secondary, and tertiary payers can be attached automatically or manually to an encounter. You can manually attach a medical specialty, a location, or one or more rendering providers to authorizations and referrals. Authorizations can be tracked for internal purposes when a payer does not require authorizations to be sent on the claim.
Primary, Secondary, and Tertiary Payers for Authorizations and Referrals
- After you attach a line-item authorization or referral to a charge and bill the claim, it will display on the claim form.
- Multiple line-item authorizations or referrals can be attached to one claim at the line-level.
- A CPT code attached to a line-item authorization or referral cannot be deleted or modified once it has been used on a previous encounter or charge. To utilize the existing authorization or referral you must remove the authorization or referral from the charge and retry the update.
- If an authorization or referral has not been used on an encounter, then you can add a CPT code to an existing claim level authorization and make it a line-level authorization.
Secondary and Tertiary Payers for Authorizations and Referrals
- For secondary and tertiary payers, if there is more than one authorization or referral that meets the CPT code range, date range, and rendering criteria. The following occurs:
- The authorization or referral window opens on the Charge Posting window and you can link the applicable referral or authorization to the charge or encounter.
- If the user closes the Charge Posting window without linking a referral or authorization, then the first authorization or referral is linked.
- If the first referral or authorization is not applicable; then you must manually link the correct authorization or referral on the Authorization Listing window or the Referral Listing window.
- For a tertiary payer, when an authorization or referral is attached, and no balance remains on the charge, the authorization or referral will link to the encounter or charge.
- You can manually unlink the referral or authorization by accessing the Authorization Listing or the Referral Listing window and selecting or deselecting the referral or authorization.
Tracking Authorizations and Referrals
Authorizations are tracked by encounters utilizing the authorization and appointments pending the authorization. Also, you can track authorizations for internal purposes when a payer does not require authorizations to be sent on the claim.
Referrals are tracked by encounters used, encounters pending, and remaining encounters.
Attaching Multiple Providers, a Specialty, or a Location to Referrals and Authorizations
When setting preferences for authorizations or referrals, you can choose either a medical specialty, a location, or one or more rendering providers. These options apply to claim-level and line-level authorizations and referrals. Use either the Authorization Code Tracking or the Referral Code Tracking window to attach these options to a referral or an authorization.
- Rendering Providers Window
- You can select a single rendering provider or multiple rendering providers. Providers are practice specific. Also, you can specify a location for the provider.
- The rendering provider list is populated from the providers listed on the Providers List window in File Maintenance. The path for this list is window.
- When providers are selected in the Rendering field on the Authorization Code Tracking window, the Specialty field becomes unavailable.
- Specialty
- You can select a single specialty to be attached to the authorization or referral. When a Specialty is selected on the Authorization Code Tracking window, the Rendering field becomes unavailable.
- The specialty list is populated from the specialties listed on the Practice tab of the Provider Information window. The path for this setting is window field.
- Location
- An authorization can be set by a single location, a single location and a specialty, or a single location and one or more rendering providers.
