EDI Claim Profile Library

File Maintenance Help for NextGen® Enterprise 8

EDI Claim Profile Library

The EDI Claim Profile library enables you to store and configure Electronic Data Interchange (EDI) claim settings in one central library. 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: 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. You can generate EDI Claim Profile Library Listing report from the EDI Claim Profile library. For more information go to NextGen Healthc

Help Guide for NextGen® Enterprise PM 8

Set Up Institutional EDI Claim Profile Rules

On the Institutional tab of the EDI Claim Profile Maintenance window, you can determine how the details appear in rendering provider loop and the referring provider full middle name for the 837I Electronic Data Interchange (EDI) claim files of specific payers. In the EDI Claim Profile Maintenance window, select the Institutional tab. To generate the full middle name instead of the middle initial of the referring provider in the EDI claim file, select the corresponding row in the Setting column for the Send 2310F Referring Provider Full Middle Name option. For the Send 2420C Rendering Provider Loop Setting option, do one of the following in the Setting column: To generate the 2420C loop with same claim and line-level rendering providers, select Always. To generate the 2420C loop with different claim and line-level rendering providers, select Only if claim and line level renderings are different. Select OK. Parent topic: EDI Claim Profile Library

Help Guide for NextGen® Enterprise PM 8

Set Up Dental EDI Claim Profile Rules

On the Dental tab of the EDI Claim Profile Maintenance window, you can determine how the details appear in referring provider full middle name, the rendering provider loop, and the service facility location loop for 837D Electronic Data Interchange (EDI) claim files of specific payers. In the EDI Claim Profile Maintenance window, select the Dental tab. To generate the full middle name instead of the middle initial of the referring provider in the EDI claim file, select the corresponding row in the Setting column for the Send 2310A Referring Provider Full Middle Name option. For the Send 2420A Rendering Provider Loop option, do one of the following in the Setting column: To generate the 2420D loop with same claim and line-level rendering providers, select Always. To generate the 2420D loop with different claim and line-level rendering providers, select Only if claim and line level renderings are different. For the Send 2420D Service Facility Location Loop option, do one of the following

Help Guide for NextGen® Enterprise PM 8

Setting Up Claims

Before you can generate claims, you must set up options to define the following: The type of information you want to display in the various claim form fields The way you want the claim forms to print The location, payer, and provider information for a valid claim creation Specialty Billing For more information about the setup and functionality of the types of billing based on speciality, go toNextGen Healthcare Success Communityand download the following user guides: Anesthesia Billing User Guide forNextGen® Enterprise PM Behavioral Health Billing User Guide forNextGen® Enterprise PM Community Health Centers User Guide forNextGen® Enterprise PM Community Health Centers include the following types of billing: Encounter Rate Billing Roll-Up Billing Dental Billing Claim Printing Library The Claim Printing library enables you to specify options that define which information prints on claim forms. Claim Modifiers Library EDI Claim Profile Library The EDI Claim Profile library enables you to

Help Guide for NextGen® Enterprise PM 8

Set Up Professional EDI Claim Profile Rules

On the Professional tab of the EDI Claim Profile Maintenance window, you can determine how the details appear in the rendering provider loop, the service facility location loops, and the referring provider full middle name for the 837P Electronic Data Interchange (EDI) claim files of specific payers. In the EDI Claim Profile Maintenance window, select the Professional tab. To generate the location loop with Place of Service (POS) 99 details in the EDI claim file, select the corresponding row in the Setting column for the Send Service Facility Location Loop with POS 99 Details option. To generate the full middle name instead of the middle initial of the referring provider in the EDI claim file, select the corresponding row in the Setting column for the Send 2310A Referring Provider Full Middle Name option. For the Send 2420A Rendering Provider Loop option, do one of the following in the Setting column: To generate the 2420A loop with rendering provider details, select Always. To generat

Help Guide for NextGen® Enterprise PM 8

Add or Modify EDI Claim Profile Library

In File Maintenance, select Libraries > EDI Claim Profile. In the EDI Claim Profile List window, do one of the following: To add a library, select open menu and 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. In the EDI Claim Profile Name field, enter a descriptive name for the library. In the Payer Rules for EDI section, do one of the following: To add payer rules, select open menu and select New. To modify payer rules, select the corresponding row from the list, select open menu, and select Open. The EDI Claim Profile Maintenance window opens. Enter an effective date and an expiration date for the payer rules. Note: Dates cannot overlap between payer rules for the same payer. If you enter overlapping dates and select OK, the application displays a message indicating that the effective and expiration dates overlap for an existing payer rule. Enter a descriptive name fo

EDI Claim Profile Library

Recommendations

EDI Claim Profile Library

Set Up Institutional EDI Claim Profile Rules

Set Up Dental EDI Claim Profile Rules

Setting Up Claims

Set Up Professional EDI Claim Profile Rules

Add or Modify EDI Claim Profile Library

EDI Claim Profile Library

Set Up Institutional EDI Claim Profile Rules

Set Up Dental EDI Claim Profile Rules

Setting Up Claims

Set Up Professional EDI Claim Profile Rules

Add or Modify EDI Claim Profile Library