NextGen Knowledge Center

Add or Modify EDI Claim Profile Library

The EDI Claim Profile library enables you to store and configure Electronic Data Interchange (EDI) claim settings. You can configure EDI claim settings based on payer requirements and control the setup involved when payers require service line level segments to be reported in the 837 claim file. The settings in this library also provide support for the 2400 loops and segments requested by payers when the details are different per charge.

After you set up the EDI Claim Profile library, you can do the following:

  • Select a practice specific EDI Claim Profile library on the Libraries tab of the Practice Preferences window.
  • Generate an EDI Claim Profile report to review the library name, dates, default EDI rules, and valid payers.
  • Select the EDI Claim Profile library on the Alt Payer tab of the Add Payer Information or Modify Payer Information window.
  1. In File Maintenance, select Libraries > EDI Claim Profile.
  2. In EDI Claim Profile List, do one of the following:
    • To add a library, select Open Menu , and then select New.
    • To modify a library, select the corresponding row from the list, select Open Menu , and then select Open.
    The EDI Claim Profile Maintenance window opens.
  3. In EDI Claim Profile Name, enter a descriptive name for the library.
  4. In Payer Rules for EDI, do one of the following:
    • To add payer rules, select Open Menu , and then select New.
    • To modify payer rules, select the corresponding row from the list, select Open Menu , and then select Open.
    The EDI Claim Profile Maintenance window opens.
  5. Enter an effective date and an expiration date for the payer rules.
  6. Enter a descriptive name for the payer rule.
  7. Do one of the following:
    • To define default payer rules for all payers that do not have specific rules defined, select Use as default EDI rules for all payers.

      The Valid Payers section becomes unavailable.

    • To define EDI rules for specific payers, leave the Use as default EDI rules for all payers check box blank, and then do the following:
      • In the Valid Payers section, double-click Open Folder .
      • In the Payers window, select one or more payers, and then select OK.
  8. Set up professional, institutional, and dental rules for the payers on the corresponding tabs as applicable.
  9. Select OK.
Add or Modify EDI Claim Profile Library