Electronic Claims File Structure

Control Segment	Identifying Header Label	Identifying Trailer Label
Interchange Envelope	ISA – Interchange Control Header	IEA – Interchange Control Trailer
Functional Group	GS – Functional Group Header	GE – Functional Group Trailer
Transaction Set	ST – Transaction Header	SE – Transaction Trailer
Loop Control Segment (Data Segments)	LS – Loop Header	LE – Loop Trailer
Interchange Acknowledgment	TA1 – Interchange Acknowledgment	There is no identifying trailer label associated with the TA1. The TA1 is a single control segment.

Help Guide for NextGen® Enterprise PM 8

837 Electronic File Creation Window

Use the 837 Electronic File Creation window to identify search criteria for claims that you want to send in an electronic file. This window has the following tabs: General, Advanced, and Practices. Each tab contains the File Options and Electronic Claims sections. File Options and Pending Electronic Claims Sections These sections display on each of the tabs for the 837 Electronic File Creation window. File Options - you can select the file for data transfer, identify the batch type, create a report, update claim requests, and send a test file. Pending Electronic Claims - displays the claims that match the search criteria on the active tab. General, Advanced, Practices, File Options, and Pending Electronic Claims Refer to the following topics for information about the fields on this window: 837 Electronic File Creation - General Tab 837 Electronic File Creation - Advanced Tab 837 Electronic File Creation Window Practices Tab 837 Electronic File Creation - File Options and Pending Electr

Help Guide for NextGen® Enterprise PM 8

Electronic Claims File Structure

Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the ANSI ASC X12N 837 Health Care Claims (837) transaction for professional claims and/or encounters to contain specific standardized information. The standardization of health care information allows health care providers to submit 837 electronic files within the NextGen In-line Edits environment. There are three types of 837 electronic files: Professional (1500 claim forms) Institutional (UB claim forms) Dental ADA Each type has the same basic electronic file structure. The 837 electronic file is structured to deliver control segments of information, which include: Interchange Control Segments Functional Group Control Segments Transaction Control Segments Loop Control Segments Interchange Acknowledgment Control Segments Each control segment usually has a beginning header label and an ending trailer label. The table below outlines each of the control segments and their identifying labels.

Help Guide for NextGen® Enterprise PM 8

837 File Structure

The organizational layout of every 837 electronic file follows a standard format. The format strategically places each control segment in a specific order because each control segment specifies the type of data that can be transmitted within that control segment. The control segment headers always identify when new segments of information are going to begin, while the control segment trailers always identify when the data within a control segment is finished. The diagram below details the standard format and placement of each control segment in an 837 electronic file. Some of the actual data submitted in these control segments may be different depending on the type of 837 file, the type of information that the control segments specify are the same for each 837 file (Professional, Institutional, and ADA). The Interchange Envelope contains the control data for the entire electronic file. The ISA segment always begins an 837 electronic file. There is only one ISA segment in an 837 and the

Help Guide for NextGen® Enterprise PM 8

837 File Structure

The organizational layout of every 837 electronic file follows a standard format. The format strategically places each control segment in a specific order because each control segment specifies the type of data that can be transmitted within that control segment. The control segment headers always identify when new segments of information are going to begin, while the control segment trailers always identify when the data within a control segment is finished. The diagram below details the standard format and placement of each control segment in an 837 electronic file. Some of the actual data submitted in these control segments may be different depending on the type of 837 file, the type of information that the control segments specify are the same for each 837 file (Professional, Institutional, and ADA). The Interchange Envelope contains the control data for the entire electronic file. The ISA segment always begins an 837 electronic file. There is only one ISA segment in an 837 and the

Help Guide for NextGen® Enterprise PM 8

Create an 837 Electronic File

Use the General tab to search for claims by form type, claim type, CPT4 codes, and by date. To access this window, select the EDI File toolbar button. The 837 Electronic File Creation window opens. On the General tab use the following table to identify your search criteria. Field Description Submitter Profile Library (required) Select the applicable submitter profile library. Pending claims that were created with this submitter profile attached to the payer will be returned in the search. The 837 electronic files are created based on submitter profiles because the settings in the submitter profile are specific to the payer, which maintains HIPAA compliancy. Claim Form (required) Select one of the following claim forms: 1500 ADA (Dental) UB. You can only include one claim form type in an 837 electronic file. This corresponds to the submitter profile option, Number of functional groups per file. Claim Type Select the claim type to narrow the search for pending claims based on the claim t

Help Guide for NextGen® Enterprise PM 8

Create an 837 Electronic File

Use the General tab to search for claims by form type, claim type, CPT4 codes, and by date. To access this window, select the EDI File toolbar button. The 837 Electronic File Creation window opens. On the General tab use the following table to identify your search criteria. Field Description Submitter Profile Library (required) Select the applicable submitter profile library. Pending claims that were created with this submitter profile attached to the payer will be returned in the search. The 837 electronic files are created based on submitter profiles because the settings in the submitter profile are specific to the payer, which maintains HIPAA compliancy. Claim Form (required) Select one of the following claim forms: 1500 ADA (Dental) UB. You can only include one claim form type in an 837 electronic file. This corresponds to the submitter profile option, Number of functional groups per file. Claim Type Select the claim type to narrow the search for pending claims based on the claim t

Electronic Claims File Structure

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837 Electronic File Creation Window

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