epm payer master file setup - welcome - munson healthcare€¦ · · 2011-07-21epm payer master...

EPM Payer Master File Setup

NEXTGEN Healthcare Information Systems, Inc. Implementation & Training © Copyright, 2009 ALL RIGHTS RESERVED Confidential and Proprietary DO NOT COPY

V55 February 2010 of 26

Setup for Payers File Maintenance > Master Lists

Financial Classes

eLearning Curriculum: Setting Up Master Lists eLearning Course: Master Lists – Financial Classes

Financial Classes are used to group payers for reporting purposes in NEXTGEN® EPM. NOTE: This table comes pre-installed. Items should be reviewed and modified as needed.

Payer Subgroupings Payer Sub-Groupings are used to group payers for reporting purposes in NEXTGEN® EPM. This is in addition to Financial Classes which are already in place as a payer grouping reporting mechanism. They are linked in the Payers table > Defaults-2 tab.




File Maintenance > Master Files > System Transaction Codes

eLearning Curriculum: Setting Up System Master Files - EPM eLearning Course: System Master Files – Transaction Codes

Transaction Codes are used in NEXTGEN® EPM during Payment Entry. They are used extensively for reporting purposes. They are attached to payers as default payment and adjustment codes when entering third party payments. The table should include codes for all types of payments, adjustments and refunds that might be posted against charges. NOTE: This table comes pre-installed. Items should be reviewed and modified as needed.




Formats

eLearning Curriculum: Setting Up System Master Files - EPM eLearning Course: System Master Files – Formats

Formats are used in NEXTGEN® to restrict users to specific policy number and/or group number formats when entering person/patient insurance information. Payer specific formats can be created and attached to the appropriate payer(s) in the Payers table > Defaults-2 tab. For example, entry of a Medicare policy number might be restricted to one of five valid formats as seen below. NOTE: This table comes pre-installed. Items should be reviewed and modified as needed.




File Maintenance > Libraries Submitter Profiles

eLearning Curriculum: EPM Setting Up Libraries eLearning Course: Libraries – Submitter Profiles

Submitter Profiles are used in NEXTGEN® EPM when creating 837 electronic claim files. A separate library will need to be created for each clearinghouse and/or direct payer for which electronic claim files will be created. The Submitter Profile Library is attached to Payers in the Payers table > Practice Tab > Claims sub-tab. NOTE: NEXTGEN® Import Wizard can be used to pre-load profiles for Gateway, Navicure and ViaTrack clearinghouses. Profiles for other clearinghouses and payers are available from the NEXTGEN Website




Claim Edits

eLearning Curriculum: EPM Setting Up Libraries eLearning Course: Libraries – Claim Edits

The Claim Edit Library enables the selection of claim edits that should run when billing encounters and generating claims in NEXTEGEN® EPM. A default Claim Edit Library is attached in Practice Preferences > Libraries tab to be used for all payers. Additional payer-specific libraries can be created and attached to those Payers in the Payers table > Practice Tab > Libraries sub-tab. NOTE: A default library comes pre-installed. Activated edits should be reviewed and modified as needed.




Claim Printing

eLearning Curriculum: EPM Setting Up Libraries eLearning Course: Libraries – Claim Printing

The Claim Printing Library enables the configuration of data as it should print on paper 1500, UB and ADA claims in NEXTGEN® EPM. A default Claim Printing Library is attached in Practice Preferences > Libraries tab to be used for all payers during the billing/claims process. Additional payer-specific libraries can be created and attached to those Payers in the Payers table > Practice Tab > Libraries sub-tab. NOTE: A default library comes pre-installed. Parameters should be reviewed and modified as needed




File Maintenance > Master Files > System Payers

eLearning Curriculum 1: Overview of Payers and Providers eLearning Course 1: Overview of the Payers System Master File eLearning Curriculum 2: Setting Up System Master Files - EPM eLearning Course 2: System Master Files – Payers Part One eLearning Course 3: System Master Files – Payers Part Two

Payers are used in NEXTGEN® EPM for filing insurance claims. Payers are linked to the person that is the subscriber of the policy. The payer(s) can then be linked to patient encounters for billing. NOTE: NEXTGEN® Import Wizard can be used to load this table.




Payer Defaults-1 Tab

Plan Number: Enter a plan number only if all patients with this payer have the same plan number on their insurance card. If blank, plan number can be entered at the patient level. Payer Alias Name: Enter an alternate name for the payer to be used on claims. This should only be used if instructed by a NEXTGEN Claims Analyst. Group Name: Enter a group name only if all patients with this payer have the same group name on their insurance card. If blank, group name can be entered at the patient level. Group Number: Enter a group number only if all patients with this payer have the same group number on their insurance card. If blank, group number can be entered at the patient level. Plan Type: Plan Type is needed for lab interfaces to Quest and LabCorp. Below are guidelines to use for the setup of each payer.

Payer Plan Type Medicare Medicare Number Medicaid Medicaid Number BC/BS Blue Shield Number HMO Payers HMO Number All Other Payers Private Number




Address: Enter the mailing address for the payer as it should appear on paper claims. Contact Phone: Enter the phone number for the payer. Source of Signature: Select if the verbiage “Signature on File” should appear on 1500 claims in Box 12 only (12), Box 13 only (13) or both Boxes 12 and 13 (12.13) Payer Website: Enter the website address for the payer. This will give end users in NEXTGEN® EPM direct access to the payer’s website from within the patient’s insurance information.




Defaults-2 Tab

Cross-over: If selected and the payer being defined is secondary to Medicare, the remaining balance after the Medicare payment will be “Forwarded to Secondary”. Therefore, a claim will not be generated from NEXTGEN® EPM for the secondary payer. If not selected and the payer being defined is secondary to Medicare, the remaining balance after the Medicare payment will be “Settled to Secondary”. Therefore, a claim will be generated from NEXTGEN® EPM for the secondary payer.

NOTE: It is suggested to clients that will be processing ERA files from Medicare, to not select this check-box on payers that could be secondary to Medicare. This allows either Forwarded or Settled to be selected based on information provided in the ERA file.

Dental payer: Select this check-box for all dental payers that are to be filed on an ADA claim form. NOTE: Set up and training for Dental payers will be covered in a separate training session and document. Require policy number: Select this check-box for all payers. Require group number: Select this check-box for payers that always have a group number. Policy Number Format: If a specific format was created in the Formats table, select it here.




Group Number Format: If a specific format was created in the Formats table, select it here. Display override policy number and co-pay: Select this check-box for payers where a single policy may cover multiple family members and each family member may have a different policy number and/or copay.

Example: John Smith is the subscriber of an Aetna policy that covers his entire family. The policy number for each family member is the same as John’s except for the two-digit suffix. The suffix differentiates the policy number for each dependent. With this option selected for the payer, the Encounter Maintenance screen in EPM will display two fields; one for the subscriber’s policy number/copay, and another for the dependent’s policy number/copay.

Family Member Policy # Copay John/Dad (Subscriber) 12345678900 $20.00 Carol/Mom 12345678901 $20.00 Greg/Child 12345678902 $10.00

Prevent modifying plan name on insurance maint: Select this check-box for all payers.




System Tab Claims Sub-Tab NOTE: The UB Claims sub-tabs in the Provider Secondary References and Provider Paper Qualifiers sections only display if the UB Claim Form options have been set up in Practice Preferences > Claims tab.

Process as Claim Type: Select as indicated on the “Provider Secondary Reference Qualifier Set Up” document provided by your NEXTGEN® EPM Implementation Specialist and/or Claims Analyst. Financial Class: Select the appropriate financial class for the payer being defined for reporting purposes. Insurance Type Code: Select as indicated on the “Provider Secondary Reference Qualifier Set Up” document provided by your NEXTGEN® EPM Implementation Specialist and/or Claims Analyst. Provider Secondary References / Claims Tab / HCFA Claims Sub-Tab: The five tabs (2010AA, 2310A, 2310B, 2310D, 2310E) for electronic 1500 claims will automatically populate based on the Process as Claim Type selected above. Provider Secondary References / Claims Tab / UB Claims Sub-Tab: The four tabs (2010AA, 2310A, 2310C, 2310E) for electronic UB claims will automatically populate based on the Process as Claim Type selected above.




Provider Secondary References / Claims Tab / ADA Claims Sub-Tab: The four tabs (2010AA, 2310A, 2310B, 2310C) for electronic ADA claims will automatically populate based on the Process as Claim Type selected above. IMPORTANT NOTE: The Provider Secondary References for HCFA, UB, and ADA claims that are automatically populated based on the Process as Claim Type selected above are for the submission of legacy provider numbers only on claims. For payers requiring dual submission of both legacy provider numbers and NPI numbers on claims, some tabs will need to be modified. Refer to the “Provider Secondary Reference Qualifier Set Up for Dual Submission” document provided by your NEXTGEN® EPM Implementation Specialist and/or Claims Analyst. For payers requiring submission of NPI numbers only on claims, some tabs will need to be modified. Refer to the “Provider Secondary Reference Qualifier Set Up for NPI Only” document provided by your NEXTGEN® EPM Implementation Specialist and/or Claims Analyst.




Electronic Claims Sub-Tab This tab allows for the selection of items that may be needed on electronic claims for the payer being defined. NOTE: In general, items on this tab should only be selected for specific payers under the instruction of a NEXTGEN Claims Analyst.

Enable NDC coding for electronic claims: Select this check-box if National Drug Code information is needed on claims for the payer.




Practice Tab For clients with multiple practices using the same payer, the Practice Tab and all of its sub-tabs allow for entry of information specific to the payer being defined for the current practice only. NOTE: The Practice tab includes the Claims, Secondary References, Other, UB, Transactions and Libraries sub-tabs. Claims Sub-Tab NOTE: NEXTGEN® Import Wizard can be used to load this tab.

HCFA / UB / ADA Claims Submitter Profile: Select the appropriate Submitter Profile to be used for electronic claims for the payer being defined. Electronic Transmitter ID: Enter the electronic ID number for the payer being defined. Refer to the Payer Listing provided by the clearinghouse.

NOTE: This field only appears if a Submitter Profile has been selected.




Primary / Secondary / Tertiary Media Type: Select either Electronic or Paper for each type of claim for the payer being defined. When Primary, force Secondary claims to paper: Do not select this check-box for any payer. The Primary/Secondary/Tertiary Media Type fields are to be used instead. When Secondary, force Tertiary claims to paper: Do not select this check-box for any payer. The Primary/Secondary/Tertiary Media Type fields are to be used instead. Secondary References Sub-Tab For clients with multiple practices using the same payer, the Secondary References Sub-Tab allows for entry of Provider Secondary References specific to the payer being defined for the current practice only. Information entered here for the current practice will override the information entered on the System tab for all other practices. NOTE: No information should be entered on this tab unless instructed to do so by a NEXTGEN Claims Analyst.




Other Sub-Tab

Authorization Required: Select this check-box for the payer being defined only if an authorization is required on every claim for every encounter for every patient with this insurance. (Example: HMO insurances at a specialty clinic) Verification Required: Select this check-box for the payer being defined only if verification of coverage is required on every encounter for every patient with this insurance. (Example: Medicaid) Accept financial responsibility of primary copay amount: Select this check-box if the copay from a patient’s primary insurance should be billed to the payer being defined (as the patient’s secondary insurance) instead of billed to the patient. Referral Support and Eligibility Support: These check-boxes display only if the “Enable Eligibility\Referral” option has been selected in Practice Preferences > General Tab. This will be used in the NEXTGEN® RTS (Real-Time Transaction Server) module. RTS provides the following functionalities:

Real-Time Referral Requests/Responses

Real-Time Referral History Requests/Responses

Real-Time Eligibility Requests/Responses

Real-Time Claim Status Requests/Responses NOTE: Set up and training for the RTS module will be covered in a separate training session by a NEXTGEN® RTS representative.




UB Sub-Tab This sub-tab will only display if the below options have been activated in Practice Preferences > Claims tab.

NOTE: The below settings will default to the Practice tab > UB sub-tab in the Payers table. Type of Facility: Select the first digit of the 3 digit code for box 4 (Type of Bill) on UB claims. Bill Classification: Select the second digit of the 3 digit code for box 4 (Type of Bill) on UB claims. Frequency of Bill: Enter the third digit of the 3 digit code for box 4 (Type of Bill) on UB claims. Source of Admission: Select the single digit code for box 15 (Admission Src) on UB claims. This setting is optional and is only needed if Admission Source is to be populated on UB claims.




The set up of the UB Sub-Tab is specific to each location within the current practice. NOTE: NEXTGEN® Import Wizard can be used to load this tab. NOTE: Set up and training for UB Claims will be covered in a separate training session and document.




Transactions Sub-Tab

Default Payment: Enter the transaction code from the Transaction Codes table that should default onto the Payment Entry screen in NEXTGEN® EPM when entering payments from the payer being defined. NOTE: This is a required entry. Default Adjustment: Enter the transaction code from the Transaction Codes table that should default onto the Payment Entry screen in NEXTGEN® EPM when entering adjustments from the payer being defined. NOTE: This is a required entry. Reason Code Library: If a specific Reason Code Library has been created for the payer being defined, select it here. If blank, the default library from Practice Preferences > Transactions tab will be used. Additional Transaction 1 – 6: Enter any additional transaction codes that should default onto the Payment Entry screen when entering transactions from the payer being defined.




Libraries Sub-Tab

Claim Edit Library: If a specific Claim Edit Library has been created for the payer being defined, select it here. If blank, the default library from Practice Preferences > Libraries tab will be used. Type of Service Library: If a specific Type of Service Library has been created for the payer being defined, select it here. If blank, the standard TOS codes from Code Tables > Type of Service will be used. Place of Service Library: If a specific Place of Service Library has been created for the payer being defined, select it here. If blank, the standard POS codes from Code Tables > Places of Service will be used. Claim Print Library: If a specific Claim Printing Library has been created for the payer being defined, select it here. If blank, the default library from Practice Preferences > Libraries tab will be used. Encounter Rate Library: If a specific Encounter Rate Library has been created for the payer being defined, select it here Managed Care Contract: If a specific Contract Library has been created for the payer being defined, select it here Participating Providers:

If a Contract Library has been selected for the payer being defined, select all rendering providers that participate with the contract.




Alt (Alternate) Payer Tab The Alternate Payer tab is used for Provider Based Billing (Split Billing). This is needed when the charges on a single encounter are to be billed to two different payers on two different types of claim forms. Example: All services except labs are to be billed to Medicare A on a UB claim. Lab services are to be billed to Medicare B on a 1500 claim. NOTE: Set up and training for” Alternate Payer for Split Billing” will be covered in a separate training session and document. NOTE: NEXTGEN® Import Wizard can be used to load this tab.




External Tab The External tab is used when interfaces will be implemented between NEXTGEN® and one or more external systems. This tab allows a cross-reference to be defined between the NEXTGEN® payer and the external system payer. NOTE: NEXTGEN® Import Wizard can be used to load this tab.

External ID: Enter the ID for the payer as it is known on the external system. External System: Select the external system to which NEXTGEN® will be interfaced.




Co-Pays Tab This tab only displays if the “Enable multiple co-pays” option has been activated in Enterprise Preferences > General Tab. The tab allows for the entry of standard co-pay amounts for the payer being defined that are based on provider specialty. Specialty is linked to each rendering provider in the Providers table > Practice tab. The appropriate co-pay amount will default onto patient encounters in NEXTGEN® EPM dependent on the rendering provider selected on the encounter. The default co-pay amount can be overridden if the “Allow Override” check-box is selected. Additional co-pay amounts can be created at the patient level.

Description: Enter a description for the co-pay being defined. Default Co-Pay Amount: Enter an amount for the co-pay being defined. Allow Override: Select this check-box if users should be able to override the default co-pay amount. Default this Co-Pay into the Enc Co-Pay for these Specialties: Select the provider specialties to which the co-pay being defined should apply.




Payers - Other Functions Import Practice Payer For clients with multiple practices using the same payer, the Practice Tab and all of its sub-tabs allow for entry of information specific to the payer being defined for the current practice only. NOTE: The Practice tab includes the Claims, Secondary References, Other, UB, Transactions and Libraries sub-tabs. The Import Practice Payer option can be accessed by right-clicking on a payer. It enables the practice specific information defined for the payer on the Practice tab for one practice to be copied to the Practice tab for another practice. Practice Access information will also be copied.

Print Payers Payer Listing reports can be accessed by right-clicking on a payer from the Payers List and selecting Print from the menu. There are seven reports available.




Practice Access For clients with multiple practices, the Practice Access option allows the ability to control which practice(s) can see and have access to which payers. The “Practice access for payer master file” option must be enabled in Enterprise Preferences > General tab. Once enabled, the Practice Access option can be accessed by right-clicking on a payer. Select the practice(s) that should see and have access to the payer.

epm payer master file setup - welcome - munson healthcare€¦ · · 2011-07-21epm payer master...

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