Medical Necessity Verification for Orders

NextGen® Adaptive Content Engine Help Enterprise 8

Medical Necessity Verification Result Values

You can view the results of medical necessity verification along with the ABN button status. The following results appear in the Medical necessity text field when the application checks an order for medical necessity. Medical Necessity Text Field Result Displayed ABN Button Action Medical Necessity Met Disabled No further action. Cannot Confirm Disabled No further action. Needs Waiver Enabled To document the status of the Advanced Beneficiary Notice (ABN) waiver, select the ABN button. Parent topic: Medical Necessity Verification for Orders

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

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

Check Medical Necessity for Laboratory and Diagnostic Order Items

Before you begin Ensure that you have the 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 configuration. For more information on Practices Preferences in File Maintenance, go to NextGen Healthcare Success Community and download the latest File Maintenance Preferences Guide for NextGen® Enterprise. Medical necessity includes a defined list of tests that are linked to medical problems. Government insurances such as Medicare Part B require approval of a test's necessity before it can be ordered and paid for. CPOE automatically checks for medical necessity when you assign a diagnosis to a laboratory and diagnostic order item. You can view the medical necessity check results and print the Advance Beneficiary Notice (ABN) for order i

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 Verification for Orders

Recommendations

Medical Necessity Verification Result Values

Medical Necessity Setup

Checking Medical Necessity for a Test

Set Up Medical Necessity Other than Medicare for Payers

Check Medical Necessity for Laboratory and Diagnostic Order Items

Select ABN Option for Failed Medical Necessity Check

Medical Necessity Verification for Orders

Medical Necessity Verification Result Values

Medical Necessity Setup

Checking Medical Necessity for a Test

Set Up Medical Necessity Other than Medicare for Payers

Check Medical Necessity for Laboratory and Diagnostic Order Items

Select ABN Option for Failed Medical Necessity Check