Checking Medical Necessity for a Test

NextGen® Enterprise EHR Help

Assign Diagnosis Toolbar

The following options are available on the Assign Diagnosis to Selected Tests panel. Option Description Check Medical Necessity This option appears if you are licensed to use the NextGen® Medical Necessity Check. Certain government insurances (Medicare part B) require approval of a test's necessity before it can be ordered and paid for. The NextGen® Medical Necessity Check uses a defined list of tests that are linked to medical problems. The list is updated quarterly. When selected, this option runs the NextGen® Medical Necessity Check against the tests and diagnosis codes selected. File Maintenance setup is required to make the NextGen® Medical Necessity Check available. Delete Failed Tests This option appears if you are licensed to use the NextGen® Medical Necessity Check. When selected, this option removes tests from the order that have failed the medical necessity check. Delete Test Removes the selected test from this order. Assign All Diagnosis Selects (assigns) all diagnoses for

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

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

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® Adaptive Content Engine Help Enterprise 8

Medical Necessity Verification for Orders

You can enable an automated process for verifying medical necessity for a practice. To use the system Medical Necessity verification function, you must select Enable Medical Necessity in the Orders/Plans section of the Practice Configuration practice template, and then enter a state or region from the State/Region field. To run the Medical Necessity check for a patient, you must document the insurance details and region in the patient’s demographics information. For more information about the Medical Necessity practice configuration, go to NextGen Healthcare Success Community, and download the latest Practice Configuration Template User Guide forNextGen®Adaptive Content Engine. orders plans If you select Enable Medical Necessity on the Practice Configuration practice template, the Medical Necessity text field and ABN button appear on the My Plan, My Custom Plan, Labs, Diagnostic Studies, Office Procedures, and Associate Multiple Diagnoses to Orders templates. Based on this medical nece

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

Checking Medical Necessity for a Test

Recommendations

Assign Diagnosis Toolbar

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

Medical Necessity Setup

Set Up Medical Necessity Other than Medicare for Payers

Medical Necessity Verification for Orders

Set Up Medical Necessity to Run Automatically

Assign Diagnosis Toolbar

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

Medical Necessity Setup

Set Up Medical Necessity Other than Medicare for Payers

Medical Necessity Verification for Orders

Set Up Medical Necessity to Run Automatically