NextGen: PM Contract Library. User Manual

Transcription

1 NextGen: PM Cntract Library User Manual Prepared by Ktenai Health Infrmatin Technlgy March 2015

2 Table f Cntents NextGen PM Cntract Library 2 Cmmn Uses fr Cntracts 2 File Maintenance 2 General Tab 2 Fee Schedule Tab 5 Mdifier Reimbursement Tab 7 Multiple Prcedure Discunting Tab 8 Link t Cntract t Payer(s) and Prviders 9 Cntract Exceptins 10 Link t Cntract Exceptin t Prvider(s) 12 Cntract Glbal Update 13 Cntract Functinality in EPM 15 Example 1: Nn-Participating Prvider Alert 15 Example 2: Deductible in Effect Prmpt 16 Example 3: Referring Physician Required Alert 17 Example 4: Authrizatin Required Alert 17 Example 5: Prrate Insurance Balance (80% / 20%) 18 Example 6: Create Zer Dllar Claim 19 Example 7: Apply C-Pay t All Line Items (90% / 10%) 19 Example 8: Autmatically Adjust Charges = Turned Off 20 Example 9: Autmatically Adjust Charges = Turned On 21 Example 10: Adjustable Allwed Amunt 22 Example 11: Allw Psitive Adjustments 23 Example 12: Cntract Exceptin fr Mid-Level Prviders 23 Example 13: Allwed Amunts Reduced based n Mdifiers and Multiple Prcedures 24 Reprts 27 Cntractual Analysis Reprt 27 Cntractual Analysis Reprt fr Medicare Cntract 28

3 NextGen PM Cntract Library Cmmn Uses fr Cntracts Streamline payment entry by defaulting the payer s allwed, payment and adjustment amunts. Autmatically adjust charges during charge psting s that A/R reflects expected reimbursement. Track expected vs. actual reimbursement with the Cntractual Analysis Reprt. Define requirements fr specific CPT4 cdes. Fr example: authrizatin required, referring prvider required, c-pay amunt, diagnsis cde required, mdifier required, etc. Nte: The infrmatin entered within a cntract applies nly when the cntracted payer is the primary insurance n the encunter. File Maintenance File Maintenance>Libraries>Cntract General Tab Cntract Name Enter a name fr the cntract. Effective/Expiratin Dates The dates entered are used in determining whether r nt t apply the cntracts rules t a particular date f service fr the patient. The cntracts Fee Schedule Page 2

4 tab als has effective and expiratin dates specified fr each CPT4 cde. Thse dates must fall within the effective/expiratin dates defined here. C-Payment n Office Enc s (Encunters) Displays the fllwing prmpt t users when the C-Payment field is left blank n the Insurance Maintenance Windw: The cpay field is a required entry fr this cntract. Are yu sure yu want t leave this screen? Yes/N. Default C-Pay Amunt Defaults the amunt indicated int the C-Pay Amunt field n the Insurance Maintenance windw. This can be used if all patients that have an insurance assciated t this cntract have the same c-pay amunt. Nte: This feature nly wrks if the enable practice payer specific infrmatin ptin in Practice Preferences is nt selected. Deductible in Effect Displays the fllwing prmpt t users when the Deductible field is left blank n the Insurance Maintenance Windw: The deductible field is a required entry fr this cntract. Are yu sure yu want t leave this screen? Yes/N. Referring Physician Required Displays the fllwing cntract edit alert t users n the Charge Psting windw fr any CPOT4 cde entered: Referring Physician is required fr this prcedure. Enable Build Level Edits Generates a claim edit failure n the Claim Prductin Status Reprt during the billing prcess and stps a claim frm being created if an encunter is missing any f the criteria defined within the cntract. Enable Drug Allwed Amunts Enables allwed amunts fr each CPT4 cde t be entered with three decimal places n the cntract s Fee Schedule tab. ($0.000) Cntract Subgrup 1 and 2 A cntract can be linked t ne r tw Cntract Subgrupings which are defined in File Maintenance/Master Lists and used t assciate prviders and cntracts tgether. Prviders linked t the same subgrup(s) in the Prviders table can easily be assigned r unassigned as participating prviders fr the cntract. Authrizatin Required Displays the fllwing cntract edit alert t users n the Charge Psting windw fr any CPT4 cde entered: Authrizatin is required fr this prcedure. Prrate Insurance Balance Charge balances n an encunter will be prrated in the Balance Cntrl windw between the primary and secndary insurances (r between the primary insurance and the patient if n secndary insurance exits). The prrated amunt is based n the fee fr service percentage defined in the cntract s fee schedule. Nte: the prrate insurance balance ptin must als be selected fr the Payer n the Practice tab>libraries sub-tab. Create Zer Dllar Claim Enables $0.00 charges t be included and billed n insurance claim frms. Unless this ptin is selected, the applicatin des nt nrmally include $0.00 charges n claims. Apply C-Pay t All Line Items Enables multiple charges n a single encunter t have a c-pay applied if the C-Pay Amunt r C-Pay % has been defined fr each CPT4 cde in the cntract s fee schedule. Unless this ptin is selected, the applicatin applies a Page 3

5 c-payment nly t the first charge entered n an encunter, regardless f the CPT4 cde entered. C-Pay Origin Determines if the C-Pay% indicated in the cntract s fee schedule shuld be based n the Allwed Amunt r the Reimbursed Amunt defined fr each CPT4 cde. Nte: The C-Pay percent calc ptin within the Payers table in File Maintenance must als be selected. Multiply Fee Schedule C-Pay by Quantity The c-pay amunt indicated fr a CPT4 cde n the Fee Schedule tab f the cntract will be multiplied by the quantity entered during charge psting. Fee fr Service Defaults FFS int the Type field fr each CPT4 cde added t the cntract s fee schedule. % f Allwed Amunt fr Participants/Nn-Participants The percentage defined here will be multiplied by the price frm the SIM Library fr any CPT4 cde nt defined in the cntract s fee schedule. The multiplied value will default nt the Payment Entry windw as the expected payment amunt. Fully Capitated/Prduce Claim fr Dcumentatin Charges fr CPT4 cdes nt defined in the cntract s fee schedule will be adjusted t a balance f $0.00 n the Payment Entry windw. The adjustment amunt is equal t the price frm the SIM Library. The adjustment cde used is the Default Adjustment cde frm the Payers table. Als defaults Capitated int the Type field fr each CPT4 cde added t the cntract s fee schedule. Autmatically Adjust Charges Charges will be adjusted at the time f entry n the Charge Psting windw. The adjustment amunt is calculated as the difference between the price frm the SIM Library and the allwed amunt frm the cntract s fee schedule. [Charge Allwed = Adjustment] Adjustable Allwed Amunt Charges will be adjusted at the time f entry n the Charge Psting windw. The adjustment amunt is calculated as the difference between the price frm the SIM Library and the reimbursed amunt frm the cntract s fee schedule plus the patient s c-pay amunt. [Charge (Reimbursed + C-Pay) = Adjustment] Default Aut-Adj Transactin Required entry if the Autmatically Adjust Charges ptin is selected. Enter the third party adjustment Transactin Cde t be used when charges are adjusted at the time f entry n the Charge Psting windw. Allw Psitive Adjustments Charges will be adjusted at the time f entry n the Charge Psting windw. If the price frm the SIM Library is less than the allwed amunt frm the cntract s fee schedule, a psitive adjustment will be added t bring the balance f the charge up t the allwed amunt. If rendering Nt Entered Assume Participating If the Rendering field is left blank n the Encunter Maintenance windw (and therefre is als left blank n the Charge Psting windw) the system will Page 4

6 Fee Schedule Tab assume that the n rendering is a participating prvider and the adjustment amunt will be calculated accrdingly. CPT4 Enter the CPT4 cde t be added t the fee schedule. Effective Date Enter the date the allwed amunt takes effect fr the CPT4 cde. The default is frm the Effective Date defined n the cntract s General Tab and can be verridden. Expiratin Date Enter the date the allwed amunt ends being in effect fr the CPT4 cde. The default is the Expiratin Date defined n the cntract s General Tab and can be verridden. Type Enter the FFS (Fee fr Service) fr the CPT4 cde. The default is FFS r Capitated depending n which ptin was selected n the cntract s General tab. Nte: If Capitated is selected, the CPT4 will be adjusted during Payment Entry. The adjustment amunt is equal t the Reimbursed amunt defined fr the CPT4 in the cntract. The adjustment cde used is the Default Adjustment cde frm the Payer s table. Multiple Prc Discunting Select the apprpriate ptin fr the CPT4 cde. N: The allwed amunt fr the CPT4 will nt be reduced. Multiple Surg: The allwed amunt fr the CPT4 cde will be reduced based n the rder/sequence f the charge n the encunter. The allwed amunt is reduced t the percentage defined n the Multiple Prcedure Discunting tab. Endscpy: The allwed amunt fr the CPT4 cde will be reduced. The allwed amunt is reduced t the difference between the allwed defined fr the CPT4 and the allwed defined fr the Base CPT4 Cde. Base CPT4 Cde Select the Base Cde fr the endscpy CPT4 Cde. Page 5

7 Nte: This field is required if Endscpy was selected in the Multiple Prc Discunting field. Nn-Facility/Facility Allws fr difference in allwed and reimbursed amunts depending n where a service is perfrmed. (E.G. Office=Nn-Facility and Inpatient Hspital = Facility) % f Chg Select this clumn (green check) if the allwed amunt fr the CPT4 cde is t be a percentage f the charge amunt frm the SIM Library. Nte: when this clumn is selected, the Allwed field becmes a % amunt, nt a $ amunt and the Participating/Nn-Participating Reimbursed fields becme unavailable. Nn-Facility Allwed Enter the nn-facility allwed amunt fr the CPT4 cde. An adjustment will be made t the charge if the nn-facility price frm the SIM Library and the nnfacility allwed amunt frm the cntract s fee schedule are nt the same. Nte: The charge will be adjusted at the time f entry n the Charge Psting windw if the Autmatically Adjust Charges ptin is selected n the cntract s General tab. Otherwise, the charge will be adjusted during Payment Entry. Participating % Enter the percentage f the allwed amunt that is expected as reimbursement fr a participating prvider. The Participating Reimbursed amunt will be calculated frm the percentage entered. Participating Reimbursed Enter the reimbursement amunt that is expected fr a participating prvider. The Participating % will be calculated frm the amunt entered. Nn-Participating %: Enter the percentage f the allwed amunt that is expected as reimbursement fr a nn-participating prvider. The Nn-Participating Reimbursed amunt will default t $0.00 as an entry is nt required in bth fields. Nn-Participating Reimbursed Enter the reimbursement amunt that is expected fr a nn-participating prvider. The Nn-Participating % will default t $0.00 as an entry is nt required in bth fields. Auth Req Select this ptin if an authrizatin is required fr the CPT4 cde. The fllwing cntract edit alert will display t users n the Charge Psting windw: Authrizatin is required fr this prcedure. Nte: This will verride the Authrizatin Required ptin setting n the General tab. Refer Req Select this ptin if a referring physician is required fr the CPT4 cde. The fllwing cntract edit alert will display t users n the Charge Psting windw: Referring Physician is required fr this prcedure. Nte: this will verride the Referring Physician Required ptin setting n the General tab. C-Pay Select this ptin if a c-payment shuld be applied t the CPT4 cde. The c-pay applied will be the amunt defined in the Default C-Pay Amunt field n the cntract s General tab. If n c-pay amunt is defined n the cntract s General tab, the c-pay Page 6

8 C-Pay % applied will be the amunt entered in the C-Pay Amunt field n the patient s Insurance Maintenance windw. If the c-payment t be applied t the CPT4 cde shuld be calculated as a percentage f the allwed amunt defined in the cntract s fee schedule, enter the percentage here. Nte: This percentage c-payment will verride bth the default C-Pay Amunt defined n the cntract s General tab and the C-Pay Amunt defined n the patient s Insurance Maintenance windw. C-Pay Amunt If the c-payment t be applied t the CPT4 cde shuld be a specific dllar amunt, enter the amunt here. Nte: This c-payment amunt will verride bth the default C-Pay Amunt defined n the cntract s General tab and the C-Pay Amunt defined n the patient s Insurance Maintenance windw. Required Diagnses If the payer requires that a specific diagnsis cde be assciated t this CPT4 cde, add the ICD9(s) here. The fllwing cntract edit alert displays t users n the Charge Psting windw if a required ICD9 cde is nt entered. Warning: The cntract requires the primary diagnsis cde t be ne f the fllwing diagnsis cde(s): cde1, cde2, cde3, etc. Required Mdifiers If the payer requires that a specific mdifier be assciated t this CPT4 cde, add the mdifier(s) here. The fllwing cntract edit alert displays t users n the Charge Psting windw if a required mdifier is nt entered: Warning: accrding t the cntract the fllwing mdifier cde(s) are required fr this prcedure: cde1, cde2, cde3, etc. Mdifier Reimbursement Tab This tab can be used if the payer reduces the allwed amunt defined fr CPT4 cdes n the Fee Schedule tab t a certain percentage when a specific mdifier r mdifier cmbinatin is used n the charge. Page 7

9 Mdifier(s) Enter a specific mdifier r mdifier cmbinatin. Percentage f Allwed Enter the percentage the allwed amunt shuld be reduced t when the specified mdifier r mdifier cmbinatin is used n a charge. Example: Mdifier 80 (Assistant Surgen) will reduce the allwed amunt t 50%. Multiple Prcedure Discunting Tab This tab can be used if the payer reduces the allwed amunt defined fr CPT4 cdes n the Fee Schedule tab t a certain percentage when thse cdes are setup as a Multiple Surg. The allwed amunt is reduced based n the charge rder/sequence n the encunter. Sequence Defaults a number as fllws and cannt be changed: First entry = 1 Secnd entry = 2 Etc. Percentage f Allwed Enter the percentage the allwed amunt shuld be reduced t when the charge falls int the defined rder/sequence n the encunter. Example: First charge: The allwed amunt will remain at 100% Secnd charge: The allwed amunt will be reduced t 75% Third charge: The allwed amunt will be reduced t 50% Page 8

10 Link t Cntract t Payer(s) and Prviders The cntract is attached t the apprpriate payer(s) n the Practice tab>libraries sub-tab and the rendering prviders that participate with the payer s cntract are selected. Managed Care Cntract Select the cntract fr the payer. Participating Prviders Select the rendering prviders that participate with the payer s cntract. Prviders that are nt selected are cnsidered nn-participating prviders. Page 9

11 The fllwing fields display nly if a Managed Care Cntract has been selected fr the payer. Prrate Insurance Balance Select this check-bx if charge balances n an encunter are t be prrated in the Balance Cntrl windw between primary and secndary insurances (r between the primary insurance and the patient if n secndary insurance exists). The prrated amunt is based n the fee fr service percentage defined in the cntract s fee schedule. Nte: The Prrate insurance balance ptin must als be selected n the Cntract>General tab and n the Payer>Practice tab>libraries sub-tab. Default Nn-Participating Prvider s Accept Assignment t N Select this check-bx t set the Assignment f Benefits t N fr the encunter when a nn-participating prvider is selected as rendering. Assignment f Benefits is fund n the Chart>Encunters tab>insurance sub-tab>verificatin sectin. Cntract Exceptins Cntract Exceptins allw differences frm the standard cntract fr allwed amunts, reimbursed amunts, etc. t be defined. The differences can be based n any f the fllwing: Prvider Prvider/Lcatin Prvider/Lcatin/Payer Example Dr. Jnes Dr. Jnes at Westminster Office Page 10

12 Create a Cntract Exceptin Right-click n the cntract and select Cntract Exceptins frm the menu. The Cntract Exceptin Maintenance windw displays. Cntract Exceptin Name Enter a name fr the exceptin being defined. Type the First Number(s) f the CPT4 Item yu want t Lcate Enter the first few digits f the CPT4(s) that yu need t have exceptin parameters defined. CPT4 / Effective / Expiratin / Auth Req / Refer Req These parameters default frm the riginal cntract setup and cannt be mdified. Nn-Facility / Facility Page 11

13 Define the fllwing exceptin parameters fr each CPT4 cde as needed: Allwed Participating % and Reimbursed Nn-Participating % and Reimbursed Authrizatin Required Referring Prvider Required C-Pay % and Amunt Example: Medicare Cntract Exceptin fr Mid-Level Prviders Link t Cntract Exceptin t Prvider(s) Once a Cntract Exceptins has been created, it is linked t the apprpriate rendering prviders in the Prviders table > Practice tab > Grup Infrmatin sectin. In the belw example, the Mid-Level Cntract Exceptin is being linked t Lisa Banks, NP at all lcatins fr Medicare. Page 12

14 Cntract Glbal Update The Cntract Glbal Update is a utility that can be used t update the Nn-Facility / Facility allwed amunts and reimbursement amunts within an existing cntract. The utility uses the RVU Library and GPCI Cdes Library (ptinal) in the calculatin f the new allwed/reimbursement amunts. The utility can be access by right-clicking n the cntract and selecting Cntract Glbal Update frm the menu. Access Cntract Glbal Update Right-click n the cntract and select Cntract Glbal Update frm the menu. The Cntract Glbal Update windw displays. Page 13

15 Filter Criteria CPT4 Starting CPT4 cde in the cntract t be updated with new fees. Thru CPT4 Ending CPT4 cde in the cntract t be updated with new fees. Effective Date Enter an Effective Date fr the selected CPT4 cdes. Nte: Only CPT4 cdes in effect n the date specified will be updated. Calculate Using RVU*GPCI RVU Library Select the RVU Library t be used in the fee update calculate. GPCI Library Select the GPCI Library t be used in the fee update calculatin, if applicable. Carrier/Lcality Select the Carrier/Lcality frm the GPCI Library t be used in the fee update calculatin, if applicable. RVU/GPCI Calculatin Create the fee update calculatin t be used. Cnversin Factr The cnversin factr entered here will be multiplied by the ttal frm the calculatin defined abve. Anesthesia Cnversin Factr The anesthesia cnversin factr entered here, if applicable, will be multiplied by the ttal frm the calculatin defined abve. Set the New Allwed Amunt t (n) 5 f the Calculated Payment The percentage entered here will be multiplied by the ttal frm the calculatin defined abve. This will becme the new allwed amunt in the cntract fr the selected CPT4 cdes. Set the New Participating Reimbursement t (n) % f the New Allwed Amunt The percentage entered here will be multiple by the new allwed amunt. This will becme the expected reimbursement amunt in the cntract fr participating prviders fr the selected CPT4 cdes. Determine the New Nn-Participating Allwed Amunt t (n) % f the New Allwed Amunt The percentage entered here will be multiple by the new allwed amunt. This will becme the allwed amunt fr nn-participating prviders fr the selected CPT4 cdes. Set the New Nn-Participating Reimbursement Amunt t (n) % f the Determined Nn-Participating Allwed Amunts The percentage entered here will be multiple by the nn-participating allwed amunt. This will becme the expected reimbursement amunt in the cntract fr nn-participating prviders fr the selected CPT4 cdes. Other Values Keep Existing Values fr Old Fee Schedule Select this check-bx t retain the current settings n the Fee Schedule tab in the cntract fr the selected CPT4 cdes. The settings include: Auth Req Authrizatin Required Refer Req Referring Prvider Required C-Pay Indicatr Page 14

16 C-Pay % C-Pay Percentage C-Pay Amunt C-Pay Dllar Amunt D nt select this check-bx if it desired t change the current setting n the Fee Schedule tab in the cntract fr the selected cdes. The settings that can be changed include: Type Select FFS (Fee fr Service) r Capitated. Auth Required Select this check-bx t activate Auth Req fr the selected cdes. Referral Required CPay Select this check-bx t activate Refer Req fr the selected cdes. Select this check-bx t activate the C-Pay Indicatr ( ) fr the selected cdes. %: If the c-pay fr the selected cdes shuld be a percentage f the allwed amunt, enter the percentage here. $: If the c-pay fr the selected cdes shuld be a specific dllar amunt, enter the amunt here. Update the Nn Facility Select this ptin t update the Nn-Facility fee rw in the cntract fr the selected cdes. Update the Facility Select this ptin t update the Facility fee rw in the cntract fr the cdes selected. Expire Old, and Create New Rw in Cntract Select this ptin t expire the existing fee rw and create a new fee rw fr the selected cdes. Update the Existing Rw in the Cntract Select this ptin t update the existing fee rw fr the selected cdes. Effective Date Enter the Effective Date fr the fee rw. Expiratin Date Enter the Expiratin Date fr the fee rw. Cntract Functinality in EPM The examples n the fllwing pages are intended t illustrate sme f the ptins available in the setup f a Cntract and hw thse ptins wrk frm an end user s perspective in EPM. Example 1: Nn-Participating Prvider Alert Lisa Banks, NP is nt selected as a participating prvider fr the Medicare cntract in the Payers table > Practice tab > Libraries sub-tab. Page 15

17 An appintment is created fr a Medicare patient with Lisa Banks, NP. A cntract edits alert displays n the Add Appintment windw. Nte: The cntract edit alert als displays when selecting Medicare as the primary insurance n the encunter during check-in and when psting charges. Example 2: Deductible in Effect Prmpt The Deductible in Effect ptin is selected in the Medicare cntract > General tab. Medicare insurance is entered fr a patient and the Deductible field is left blank ($0.00) n the Insurance Maintenance windw. A cntract prmpt displays when user clicks OK t save the insurance infrmatin. Page 16

18 Example 3: Referring Physician Required Alert The Ref Req ptin is selected in the Cigna cntract > Fee Schedule tab fr CPT4 cde (Office Cnsult). An encunter is created with Cigna as primary insurance. The Referring prvider field was left blank n the Encunter Maintenance windw. A cntract edits alert displays n the Charge Psting windw fr Nte: The cntract edit alert will nt display if a referring prvider is entered n the encunter prir t psting charges. Example 4: Authrizatin Required Alert The Auth Req ptin is selected in the Cigna cntract > Fee Schedule tab fr CPT4 cde (MRI Cervical Spine). A valid authrizatin is nt entered fr Cigna prir t the encunter being created. An encunter is created with Cigna as primary insurance. A cntract edits alert displays n the Charge Psting windw fr Nte: The cntract edit alert will nt display if a valid authrizatin is entered prir t psting charges. Page 17

19 Example 5: Prrate Insurance Balance (80% / 20%) The Prrate Insurance Balance ptin is selected in the Medicare cntract > General tab. The Prrate Insurance Balance ptin is selected in the Medicare payer > Practice tab > Libraries sub-tab. The cntract s allwed amunts are defined as fllws: = $95.00 with 80% expected reimbursement = $20.00 with 80% expected reimbursement An encunter is created with Medicare as primary and AARP as secndary. 20% f Medicare s allwed amunts are prrated t Ins2 n the Charge Psting windw. Nte: If there is n secndary insurance n the encunter, 20% f allwed amunts are prrated t Pat Amt. Page 18

20 Example 6: Create Zer Dllar Claim The Create Zer Dllar Claim ptin is selected in the Medicare cntract > General tab. An encunter is created with Medicare as primary insurance. A (Pst Op Fllwup) charge is entered fr $0.00. The charge is flagged t be released (R) and sent n a claim fr t Ins1 (Medicare). Example 7: Apply C-Pay t All Line Items (90% / 10%) The Apply C-Pay t All Line Items ptin is selected in the Cigna cntract > General tab. The cntract s allwed amunts are defined as fllws: = $ with 10% c-pay = $25.00 with 10% c-pay = $25.00 with 10% c-pay An encunter is created with Cigna as primary insurance. The 10% f Cigna s allwed amunt is autmatically mved t the patient (Pat Amt) as the c-pay fr each charge n the Charge Psting windw. Page 19

21 Example 8: Autmatically Adjust Charges = Turned Off The Autmatically Adjust Charges ptin is nt selected in the Cigna cntract > General tab. The SIM Library price fr a is $ The cntract s allwed amunt fr is $ An encunter is created with Cigna as primary insurance. A charge is entered n the encunter in the Charge Psting windw. The encunter is billed. The cntract s allwed amunt f $ defaults int the Payment Entry windw. The cntract s reimbursed amunt f $90.00 defaults int the Payment Entry windw. [Allwed X 90% = Payment] [$ X 90% = $90.00] The cntract s adjusted amunt f $10.00 defaults int the Payment Entry windw. [Charge Allwed = Adjustment] [$ $ = $10.00] Page 20

22 Example 9: Autmatically Adjust Charges = Turned On The Autmatically Adjust Charges ptin is selected in the Cigna Cntract > General tab. The SIM Library price fr a is $ The cntract s allwed amunt fr is $ An encunter is created with Cigna as primary insurance. A charge is entered n the encunter in the Charge Psting windw. A cntract edits alert displays n the Charge Psting windw fr the indicating a $10.00 adjustment has been created. [Charge Allwed = Adjustment] [$ $ = $10.00] The cntract s allwed amunt f $ defaults int the Payment Entry windw. The cntract s reimbursed amunt f $90.00 defaults int the Payment Entry windw. [Allwed X 90% = Payment] [$ X 90% = $90.00] The cntract s adjustment amunt f $10.00 des nt default int the Payment Entry windw because it ccurred at het time f Charge Psting. Page 21

23 Example 10: Adjustable Allwed Amunt The Autmatically Adjust Charges and Adjustable Allwed Amunt ptins are selected in the Aetna cntract > General tab. The Sim Library price fr a is $ The cntract s reimbursed amunt f is $ An encunter is created with Aetna as primary insurance fr a patient with a c-pay f $ A charge is entered n the encunter in the Charge Psting windw. The cntract edits alert displays n the Charge Psting windw fr the indicating a $10.00 adjustment has been created. [Charge (Reimbursed + C-Pay) = Adjustment] [$80.00 ($ $15.00) = $10.00] An encunter is created with Aetna as primary insurance fr anther patient with a cpay f $ A charge is entered n the encunter in the Charge Psting windw. A cntract edits alert displays n the Charge Psting windw fr the indicating a $15.00 adjustment has been created. [Charge (Reimbursed + C-Pay) = Adjustment] [$80.00 ($ $10.00) = $15.00] Page 22

24 Example 11: Allw Psitive Adjustments The Autmatically Adjust Charges and Allw Psitive Adjustments ptins are selected in the Cigna cntract > General tab. SIM Library prices are defined as fllws: = $ = $35.00 Cntract allwed amunts are defined as fllws: = $ = $40.00 Nte: The allwed amunt is greater than the charge amunt An encunter is created with Cigna as primary insurance. Bth the and charges are entered n the encunter in the Charge Psting windw. A cntract edits alerts display n the Charge Psting windw indicating a $ adjustment (negative) has been created fr the and a $5.00 adjustment (psitive) has been created fr the Example 12: Cntract Exceptin fr Mid-Level Prviders The Autmatically Adjust Charges ptins is selected in the Medicare cntract > General tab. The SIM Library price fr a is $ The Medicare cntract s allwed amunt fr is $ The Medicare cntract exceptins allwed amunt fr is $90.00 fr Mid-Level Prviders. AN encunter is created with Lisa Banks, NP as rendering and Medicare as primary insurance. A charge is entered n the encunter in the Charge Psting windw. A cntract edits alert displays n the Charge Psting windw fr indicating a $20.00 adjustment has been created. [Charge Allwed = Adjustment] [$ $90.00 = $20.00] Page 23

25 Example 13: Allwed Amunts Reduced based n Mdifiers and Multiple Prcedures This example illustrates hw the allwed amunts fr surgical prcedures can be reduced based n mdifiers entered n the charges and the charge rder/sequence when multiple prcedures are perfrmed. SIM Library prices are defined as fllws: SIM/CPT4 Cde Price $ $ $ $400 The Medicare cntract > Fee Schedule tab is setup fr each f the abve CPT4 cdes as fllws: CPT4 Cde Multiple Prc Discunting Allwed Multiple Surg (Yes) $800 Page 24

26 CPT4 Cde Multiple Prc Discunting Allwed Multiple Surg (Yes) $400 CPT4 Cde Multiple Prc Discunting Allwed Multiple Surg (Yes) $450 CPT4 Cde Multiple Prc Discunting Allwed N $200 The Medicare cntract > Mdifier Reimbursement Tab is setup as fllws: Mdifier 59 (Distinct Prcedure/Service) and/r Mdifier 80 (Assist Surgen) are defined t reduce the Allwed Amunt t $25% f the amunt defined in the cntract s Fee Schedule tab. Mdifier % f Allwed % 80 25% Page 25

27 The Medicare cntract > Multiple Prcedure Discunting tab is setup as fllws: Multiple Prcedure Discunting is defined t nt reduce the Allwed Amunt n the first prcedure (100%) but reduce the allwed amunts n the secnd, third, etc. prcedures (50%). Sequence % f Allwed 1 100% 2 r mre $50% Charge Psting and Cntract Aut-Adjustments Based n the abve setup in the Medicare cntract s Fee Schedule tab, Mdifier Reimbursement tab, and Multiple Prcedure Discunting tab, the Charge Psting screen belw shws the allwed amunt that was calculated fr each charge and the resulting adjustment amunt. Calculatin f Allwed Amunt [Final Calculated Allwed = Cntract Allwed Cntract Mdifier Reductin Cntract Multiple Prcedure Reductin] Calculatin f Adjustment Amunt [Adjustment Amunt = Charge Final Calculated Allwed] Page 26

28 Reprts Reprts > Accunts Receivable Cntractual Analysis Reprt Explanatin f Clumns Cnt Allwd Amunt Allwed amunt defined in the cntract fr the CPT4 cde. Act Allwd Amt Actual allwed amunt frm payer (EOB) entered during payment entry. Diff Allwd Amt Difference between the allwed amunt defined in the cntract fr the CPT4 cde and the actual allwed amunt entered during payment entry. If $0.00: Cntract allwed amunt and payer allwed amunt are the same. If > $0.00 r < $0.00: There is a discrepancy between cntract and payer allwed amunts. Cnt Pay Amt Payment amunt defined in the EPM cntract fr the CPT4 cde. Act TP Pay Amt Actual payment amunt frm payer (EOB) entered during payment entry. Diff Pay Amt Difference between the payment amunt defined in the cntract fr the CPT4 cde and the actual payment amunt entered during payment entry. If $0.00: Cntract reimbursed amunt and payer reimbursed amunt are the same. If > $0.00 r < $0.00: There is a discrepancy between cntract and payer reimbursed amunts. Page 27

29 Cnt Adj Amt Adjust amunt defined in the EPM cntract fr the CPT4 cde. Act Adj Amt Actual adjustment amunt frm payer (EOB) entered during payment entry. Diff Adj Amt Difference between the adjustment amunt defined in the EPM cntract fr the CPT4 cde and the actual adjustment amunt entered during payment entry. If $0.00: Cntract adjustment amunt and payer adjustment amunt are the same. If > $0.00 r < $0.00: There is a discrepancy between cntract and payer adjustment amunts. Cntractual Analysis Reprt fr Medicare Cntract Srted by Rendering Prvider Page 28

30 Srted by Service Lcatin Srted by CPT4 Cde Page 29