837d

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Updated:05/16/2008

Health Care Claim: Dental
Management Systems Consulting, Inc.
VERSION: 1.0 DRAFT

Author: Skip Stein

837
Health Care Claim: Dental
Functional Group=HC

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment.For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

Heading:
Pos Id Segment Name Req Max Use Repeat Notes Usage
005 ST Transaction Set Header M 1
010 BHT Beginning of Hierarchical Transaction M 1
015 REF Transmission Type Identification O 1
Loop ID - 1000A 1
020 NM1 Submitter Name O 1 N1/020
025 N2 Additional Submitter Name Information O 1
045 PER Submitter Contact Information O 2
Loop ID - 1000B 1
020 NM1 Receiver Name O 1 N1/020
025 N2 Receiver Additional Name Information O 1
Detail:
Pos Id Segment Name Req Max Use Repeat Notes Usage
Loop ID - 2000A >1
001 HL Billing/Pay-to Provider Hierarchical Level M 1
003 PRV Billing/Pay-to Provider Specialty Information O 1
010 CUR Foreign Currency Information O 1
Loop ID - 2010AA 1
015 NM1 Billing Provider Name O 1 N2/015
020 N2 Additional Billing Provider Name Information O 1
025 N3 Billing Provider Address O 1
030 N4 Billing Provider City/State/ZIP Code O 1
035 REF Billing Provider Secondary Identification Number O 5
035 REF Claim Submitter Credit/Debit Card Information O 8
Loop ID - 2010AB 1
015 NM1 Pay-to Provider’s Name O 1 N2/015
020 N2 Additional Pay-to Provider Name Information O 1
025 N3 Pay-to Provider’s Address O 1
030 N4 Pay-to Provider City/State/Zip O 1
035 REF Pay-to Provider Secondary Identification Number O 5
Loop ID - 2000B >1
001 HL Subscriber Hierarchical Level M 1
005 SBR Subscriber Information O 1
Loop ID - 2010BA 1
015 NM1 Subscriber Name O 1 N2/015
020 N2 Additional Subscriber Name Information O 1
025 N3 Subscriber Address O 1
030 N4 Subscriber City/State/ZIP Code O 1
032 DMG Subscriber Demographic Information O 1
035 REF Subscriber Secondary Identification O 4
035 REF Property and Casualty Claim Number O 1
Loop ID - 2010BB 1
015 NM1 Payer Name O 1 N2/015
020 N2 Additional Payer Name Information O 1
025 N3 Payer Address O 1
030 N4 Payer City/State/ZIP Code O 1
035 REF Payer Secondary Identification Number O 3
Loop ID - 2010BC 1
015 NM1 Credit/Debit Card Holder Name O 1 N2/015
020 N2 Additional Credit/Debit Card Holder Name Information O 1
035 REF Credit/Debit Card Information O 3
Loop ID - 2000C >1
001 HL Patient Hierarchical Level O 1
007 PAT Patient Information O 1
Loop ID - 2010CA 1
015 NM1 Patient Name O 1 N2/015
020 N2 Additional Name Information O 1
025 N3 Patient Address O 1
030 N4 Patient City/State/ZIP Code O 1
032 DMG Patient Demographic Information O 1
035 REF Patient Secondary Identification O 5
035 REF Property and Casualty Claim Number O 1
Loop ID - 2300 100
130 CLM Claim Information O 1
135 DTP Date - Admission O 1
135 DTP Date - Discharge O 1
135 DTP Date - Referral O 1
135 DTP Date - Accident O 1
135 DTP Date - Appliance Placement O 5
135 DTP Date - Service O 1
145 DN1 Orthodontic Total Months of Treatment O 1
150 DN2 Tooth Status O 35
155 PWK Claim Supplemental Information O 10
175 AMT Patient Amount Paid O 1
175 AMT Credit/Debit Card - Maximum Amount O 1
180 REF Predetermination Identification O 5
180 REF Service Authorization Exception Code O 1
180 REF Original Reference Number (ICN/DCN) O 1
180 REF Referral Identification O 1
180 REF Claim Identification Number for Clearinghouses and Other Transmission Intermedia O 1
190 NTE Claim Note O 20
Loop ID - 2310A 2
250 NM1 Referring Provider Name O 1 N2/250
255 PRV Referring Provider Specialty Information O 1
260 N2 Additional Referring Provider Name Information O 1
271 REF Referring Provider Secondary Identification O 5
Loop ID - 2310B 1
250 NM1 Rendering Provider Name O 1 N2/250
255 PRV Rendering Provider Specialty Information O 1
260 N2 Additional Rendering Provider Name Information O 1
271 REF Rendering Provider Secondary Identification O 5
Loop ID - 2310C 1
250 NM1 Service Facility Location O 1 N2/250
260 N2 Additional Service Facility Location Name Information O 1
271 REF Service Facility Location Secondary Identification O 5
Loop ID - 2320 10
290 SBR Other Subscriber Information O 1 N2/290
295 CAS Claim Adjustment O 5
300 AMT Coordination of Benefits (COB) Payer Paid Amount O 1
300 AMT Coordination of Benefits (COB) Approved Amount O 1
300 AMT Coordination of Benefits (COB) Allowed Amount O 1
300 AMT Coordination of Benefits (COB) Patient Responsibility Amount O 1
300 AMT Coordination of Benefits (COB) Covered Amount O 1
300 AMT Coordination of Benefits (COB) Discount Amount O 1
300 AMT Coordination of Benefits (COB) Patient Paid Amount O 1
305 DMG Other Insured Demographic Information O 1
310 OI Other Insurance Coverage Information O 1
Loop ID - 2330A 1
325 NM1 Other Subscriber Name O 1 N2/325
330 N2 Additional Other Subscriber Name Information O 1
332 N3 Other Subscriber City/State/Zip Code O 1
340 N4 Other Subscriber City/State/Zip Code O 1
355 REF Other Subscriber Secondary Identification O 3
Loop ID - 2330B 1
325 NM1 Other Payer Name O 1 N2/325
330 N2 Additional Other Payer Name Information O 1
345 PER Other Payer Contact Information O 2
350 DTP Claim Paid Date O 1
355 REF Other Payer Secondary Identifier O 3
355 REF Other Payer Referral Number O 1
355 REF Other Payer Claim Adjustment Indicator O 1
Loop ID - 2330C 1
325 NM1 Other Payer Patient Information O 1 N2/325
355 REF Other Payer Patient Identification O 3
Loop ID - 2330D 1
325 NM1 Other Payer Referring Provider O 1 N2/325
355 REF Other Payer Referring Provider Identification O 3
Loop ID - 2330E 1
325 NM1 Other Payer Rendering Provider O 1 N2/325
355 REF Other Payer Rendering Provider Identification O 3
Loop ID - 2400 50
365 LX Line Counter O 1 N2/365
380 SV3 Dental Service O 1
382 TOO Tooth Information O 32
455 DTP Date - Service O 1
455 DTP Date - Prior Placement O 1
455 DTP Date - Appliance Placement O 1
455 DTP Date - Replacement O 1
460 QTY Anesthesia Quantity O 5
470 REF Service Predetermination Identification O 1
470 REF Referral Number O 1
470 REF Line Item Control Number O 1
475 AMT Approved Amount O 1
485 NTE Line Note O 10
Loop ID - 2420A 1
500 NM1 Rendering Provider Name O 1 N2/500
505 PRV Rendering Provider Specialty Information O 1
510 N2 Additional Rendering Provider Name Information O 1
525 REF Rendering Provider Secondary Identification O 5
Loop ID - 2420B 1
500 NM1 Other Payer Referral Number O 1 N2/500
525 REF Other Payer Referral Number O 1
Loop ID - 2430 25
540 SVD Line Adjudication Information O 1 N2/540
545 CAS Service Adjustment O 99
550 DTP Line Adjudication Date O 1
555 SE Transaction Set Trailer M 1

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