EDI Files Overview

Electronic Data Interchange (EDI) is a method of transmitting business information between two computers. This information is used to determine how a claim should be formatted and sent to the payer. In other words, the EDI is the DNA of a claim.

Outgoing EDI Information

When a claim is submitted, the RCM sends an EDI file to the clearinghouse for review. Once the clearinghouse completes its review process, the file is forwarded to an intermediary for additional review before being sent to the payer. 

In the Record Center

All claims submitted (or marked as submitted) can be found in the Record Center under Insurance Claims. When one or more claims are submitted at the same time, the system groups them into a batch and assigns them a control (internal claim) number. Let's review how to locate and download the batch EDI information.

1. Navigate to the Record Center > Insurance Claims > Batches.
   
2. Select the Control Number of the desired batch.
   
3. Finally, click the desired option to download the EDI batch:
   • Download Batch Claims as XML to download the entire batch in an XML format.
   • Download Batch Claims Institutional EDI File to download the Institutional Claims from the batch.
   • Download Batch Claims Professional EDI File to download the Professional Claims
   • Bulk Download Claim EDI Files to download the entire batch.
      

Incoming EDI Information 

After the payer receives the claim and adjudicates it, they send the EOB (Explanation of Benefits), also known as a Remit or 835 file, using the same process. When the clearinghouse receives the EOB, the EDI from that file is ported into the RCM. The system reads the information from the EDI file and applies the payment to the claim. 

In the Record Center

Payments received for a claim, regardless of the delivery method, can always be found in the Record Center under the Insurance Payment section. Let's review how to locate and download payment-related EDI files. 

1. Navigate to Record Center > Insurance Payments > Payment Collections.
   
2. Select the Check Number to open the collection.
    
3. In the collection window, select View EOBs to view associated payments.
   
    

Uploading EDI information

Users who post payments manually will now be able to upload EDI information directly into the RCM. Managing Organization Users as well as Organization Users will require special permission to edit and import insurance payment information. 

1. Navigate to the Work Center > Insurance Payments > Enter Insurance Payment Collections.
   
2. Next, click Import EDI.
3. Select the Practice.
   
4. Then select the Source.
   
5. Click Choose File, then select the desired file you wish to upload.
   
6. Finally, select Import to complete the process.
   

Note: If a payment cannot be matched during EDI import, the system will route it to the Review Payments section for manual matching.