5010 Electronic Claim Loop and Segment Editor

With the 5010 Electronic Claim Loop and Segment Editor function, you can set up special requirements for your 5010 electronic claim files that deviate from the standard requirements. CGM maintains the standard payer rules in the background, but you can manage payer-specific or carrier-specific customizations yourself using this Editor. For example, practices submitting claims through a Direct Connection will likely have at least one custom profile defined, because the header loop will contain different information than what would be sent, by default, through CGM eMEDIX.

You can set up as many profiles as necessary for your particular circumstances and use them in as many rules as necessary. A profile must be attached to a rule for it to be in effect.

NOTE: Loops and segments are advanced features that require a higher skill set than those of the standard user. It is strongly recommended that the user profiles for your designated administrator(s) of this feature have a higher functional security level than standard users in your practice. Functional security levels are maintained under System > User Management.

5010 Electronic Claim Loop and Segment Editor Screen

The Editor screen includes two tabs:

Loop and Segment Profile Rules tab – a tree view of the rules that have been defined. When you first open the Editor, before any custom profile rules have been defined for your practice, you will see one Default Profile. As you create more profile rules, they appear in the tree.
All Profiles tab – a list of all of the profiles that have been created, with an indication of whether each profile is currently used in a rule. A profile must be associated with a rule to be in effect.

Action Column Functions

History – Click History in the Action Column to view a list of changes that have been made to rules. The current version (what you saw on the Loop and Segment Profile Rules tab before clicking History) is indicated by the word Visible. To view a different version of the rules in effect, click the View link for that entry. Each version is listed with the date and the user who made the change.

New L/S Profile – Click to create a new Loop and Segment profile.

Adding a New Profile

Click New L/S Profile in the Action Column.
Select the appropriate Base X12 Definition.

Type a Description for the profile.

The next screen is where you will define the profile. It includes a list of all of the loops in a claim file that can be edited, before the claim is sent out.

Each loop contains segments and each segment contains elements. The box with the “l” on it is your visual cue for a loop; it is referred to as the “Loop icon.”

If the Loop icon is purple, the loop is currently active.
If the Loop icon is grey, the loop is currently inactive.
If there is a lock symbol next to the loop icon, the loop may not be edited.
Each loop contains one or more segments. To expand a loop to see the segments within it, click the Loop icon.

The box with the “s” on it is your visual cue for a segment; it is referred to as the “Segment icon.”

If the Segment icon is blue, the segment is currently active.
If the Segment icon is grey, the segment is currently inactive.
If there is a lock symbol next to the Segment icon, the segment may not be edited—regardless of whether it is active or inactive.
Each segment contains one or more elements within it. To expand a segment to see the elements within it, click the Segment icon.

The box with the “e” on it is your visual cue for an element; it is referred to as the “Element icon.”

If the Element icon is green-blue, the element is currently active.
If the Element icon is grey, the element is currently inactive.
If there is a lock symbol next to the Element icon, the element may not be edited—regardless of whether it is active or inactive.
If there is a profile symbol next to the Element icon, it means the value of the element is pulled from an existing billing profile in the Billing Profile Rules menu.
If an element is highlighted in orange, it means it has been modified using this Editor.
In most cases, the element is the end point; however, some elements may have one or more components within them. To see the components, click the Element icon.

Note - The icon colors may appear differently on your screen depending on your settings.

To quickly view all changes for the profile, click the Expand Customs Action Column button. The loops and segments for any modified elements will expand to show the highlighted, modified element.

Navigate to the loop and segment you want to customize (for example, Loop 1000A Segment NM1).
In the X12 Editor window, you may do the following.

To disable the element, click the Active check box, and click Disable from the drop-down list.
To enable the element, click the Active check box, and click Enabled from the drop-down list.
To set a value for an enabled element, click the Value check box and then type the value into the Value box or click the ellipsis button to access a list from which to select.

The Claim Data Properties window opens. Select the property you want to send (for example, to override the Submitter Name, select PatientDetail and then RelationshipStatus).

Click Save on the X12 Editor window and Save again to return to the rule tree screen.
Add the new profile to an existing rule, or create a new rule for the specific payer that requires this customization.

Adding a New Rule
You can add a rule that links a profile to a specific condition (such as a carrier, form number, or plan code).

On the Loop and Segment Profile Rules tab, click Start on the rule tree and then click New Rule Below.
In the When field, select the criteria the rule should match against. Available options include Insurance Carrier, Insurance Form Number, Insurance Plan Code, Doctor, Form Type, and Location.
In the Equals field, type or select the value the criteria must equal for the rule to apply.
In the Use field, select the profile to apply when the rule matches.
Click Insert to add the rule to the tree, and then click Save to save the changes.

Notes

The Editor is preconfigured with a Default Profile. CGM updates the Default Profile with the standard payer rules as part of regular maintenance, so most practices do not need to modify the Default Profile directly. Use new profiles and rules to handle payer-specific customizations.
The Anesthesia claim configuration requires three loop/segment overrides: Loop 2400 SV1-03 Value = UN; Loop 2400 SV1-04 Value = @Claim.Procedures.Multiplier; Loop 2300 Segment NTE Value = @Claim.Calculated.ClaimNoteAnesthesia. Add these overrides to an existing Profile or create a new Profile and Rule for Anesthesia claims to prevent denials when the carrier requires start and stop time in the claim level note.
See Billing Profile Rules for detailed samples to set up additional rules. Any rules defined here apply only after the Editor's Default Profile has been evaluated.

Related Topics

Billing Profile Rules
5010 Claim Hold Rules
5010 Claim Exception Rules
5010 Submitter ID Rules
Electronic Direct Connect Claims Integration (Self-Hosted Direct Connect clients only)