837D Dental Claim Schema

Claim

Loop: 2300, Segment: CLM JSON Example Open API Schema
NameDescriptionTypeEDI Element
idUnique payment identifier assigned by the converterString
objectTypeType of this object, set to 'CLAIM'String
patientControlNumberIdentifier used to track a claim from creation by the health care provider through paymentStringCLM01
chargeAmountCharge amountNumberCLM02
patientPaidAmountPatient paid amountNumberAMT02 *F5
facilityCodePlace of service code (professional/dental) or UB facility code (institutional) from the original claim
View codes and descriptions
CodeCLM05-1
frequencyCodeFrequency code
View codes and descriptions
CodeCLM05-3
serviceDateFromThe earliest service date from service linesDate
serviceDateToThe latest service date from service linesDate
subscriberThe insured (subscriber)SubscriberLoop: 2000B
patientPatient if different from the the insured (subscriber)PatientLoop: 2110CA
otherSubscribersOther subscribers and their payer's informationList of OtherSubscriberLoop: 2320
serviceLinesService linesList of DentLineLoop: 2400
transactionParent EDI transaction for this objectTransaction837
providerSignatureIndicatorProvider signature indicatorStringCLM06
assignmentParticipationCodeAssignment participation codeStringCLM07
assignmentCertificationIndicatorAssignment certification indicatorStringCLM08
releaseOfInformationCodeRelease of information codeStringCLM09
specialProgramCodeSpecial program codeStringCLM12
delayReasonCodeDelay reason codeStringCLM20
referralNumberReferral numberStringREF02 *9F
priorAuthorizationNumberPrior authorization numberStringREF02 *G1
repricedReferenceNumberRepriced reference numberStringREF02 *9A
adjustedRepricedReferenceNumberAdjusted repriced reference numberStringREF02 *9C
medicalRecordNumberMedical record numberStringREF02 *EA
accidentDateAccident dateDateDTP03 *439
orthodonticBandingDateOrthodontic banding dateDateDTP03 *452
repricerReceivedDateRepricer received dateDateDTP03 *050
orthodonticInfoOrthodontic infoOrthodonticInfo
toothStatusesTooth statusesList of ToothStatus
clearinghouseTraceNumberClearinghouse trace numberStringREF02 *D9
originalReferenceNumberOriginal reference numberStringREF02 *F8
serviceAuthorizationExceptionCodeService authorization exception codeStringREF02 *4N
predeterminationOfBenefitsIdentifierPredetermination of benefits identifierStringREF02 *G3
fixedFormatRecordsFixed format recordsList of StringK301
claimNoteFree-form comments or instructions. All note segments are concatenated together into this field.StringNTE02
billingProviderBilling providerPartyNM1 *85
providersProviders for this claim, except for the billing providerList of Party
diagsDiagnosis codes
View codes and descriptions
List of Code
attachmentsAttachmentsList of AttachmentPWK

Orthodontic Info

Segment: DN1 Open API Schema
NameDescriptionTypeEDI Element
treatmentMonthsCountTreatment months countNumberDN101
treatmentMonthsRemainingCountTreatment months remaining countNumberDN102
treatmentIndicatorTreatment indicatorStringDN104

Tooth Status

Segment: DN2 Open API Schema
NameDescriptionTypeEDI Element
toothNumberTooth numberStringDN201
statusCodeStatus codeStringDN202

Service Line

Loop: 2400, Segment: SV3 Open API Schema
NameDescriptionTypeEDI Element
sourceLineIdLine item control numberStringREF02 *6R
oralCavityDesignationCodesOral cavity designation codesList of StringSV304
prosthesisCrownOrInlayCodeProsthesis crown or inlay codeStringSV305
predeterminationOfBenefitsIdentifierPredetermination of benefits identifierStringREF02 *G3
repricedReferenceNumberRepriced reference numberStringREF02 *9A
adjustedRepricedReferenceNumberAdjusted repriced reference numberStringREF02 *9D
priorAuthorizationPrior authorizationStringREF02 *G1
referralNumberReferral numberStringREF02 *9F
chargeAmountCharge amountNumberSV302
salesTaxAmountSales tax amountNumberAMT02 *T
serviceDateFromService date fromDateDTP03 *472
serviceDateToService date toDateDTP03 *472
priorPlacementDatePrior placement dateDateDTP03 *441, DTP03 *139
orthodonticBandingDateOrthodontic banding dateDateDTP03 *452
replacementDateReplacement dateDateDTP03 *446
treatmentStartDateTreatment start dateDateDTP03 *196
treatmentCompletionDateTreatment completion dateDateDTP03 *198
unitTypeUnit typeStringSV304
unitCountUnit countNumberSV305
procedureProcedure
View codes and descriptions
ProcedureSV302 *HC, SV302 *AD, SV302 *WK, SV302 *IV
attachmentsAttachmentsList of AttachmentPWK
providersProviders for this service lineList of Party
adjudicationsAdjudicationsList of AdjudicationSVD
Loop: 2430
adjustmentsCopy of line adjustments from the adjudication list for backward compatibilityList of AdjustmentCAS
fixedFormatRecordsFixed format recordsList of StringK301
toothInfosTooth infosList of ToothInfo
diagPointersDiagnosis pointers. Each pointer is an index of the diagnosis in the 'diags' array at the claim level.List of IntegerSV302
diagsCopy of diagnosis codes from the claim based on diagnosis pointers
View codes and descriptions
List of CodeSV302

Tooth Info

Segment: TOO Open API Schema
NameDescriptionTypeEDI Element
codeCodeStringTOO02
surfaceCodesSurface codesList of StringTOO03

Subscriber

NameDescriptionTypeEDI Element
payerResponsibilitySequencePayer responsibility sequenceStringSBR01
relationshipTypeRelationship typeStringSBR02
groupOrPolicyNumberGroup or policy numberStringSBR03
groupNameGroup nameStringSBR04
claimFilingIndicatorCodeClaim filing indicator codeStringSBR09
insurancePlanTypeInsurance plan typeStringSBR09
personPersonPersonWithDemographicNM1
deathDateDeath dateDatePAT06
weightPatient weight in poundsNumberPAT09
pregnancyIndicatorPregnancy indicatorStringPAT09
propertyCasualtyClaimNumberProperty casualty claim numberStringREF02 *Y4
payerPayerPartyNM1 *PR
Loop: 2330B

Patient

NameDescriptionTypeEDI Element
personPersonPersonWithDemographicNM1
deathDateDeath dateDatePAT06
weightPatient weight in poundsNumberPAT09
pregnancyIndicatorPregnancy indicatorStringPAT09

Other Subscriber

NameDescriptionTypeEDI Element
payerResponsibilitySequencePayer responsibility sequenceStringSBR01
relationshipTypeRelationship typeStringSBR02
groupOrPolicyNumberGroup or policy numberStringSBR03
groupNameGroup nameStringSBR04
claimFilingIndicatorCodeClaim filing indicator codeStringSBR09
insurancePlanTypeInsurance plan typeStringSBR09
personPersonPersonWithDemographicNM1
adjustmentsClaim-level adjustments from this payerList of AdjustmentCAS
payerPaidAmountPayer paid amountNumberAMT02 *D
nonCoveredAmountNon covered amountNumberAMT02 *A8
remainingPatientLiabilityAmountRemaining patient liability amountNumberAMT02 *EAF
payerPriorAuthorizationNumberPayer prior authorization numberStringREF02 *G1
payerReferralNumberPayer referral numberStringREF02 *9F
payerClaimControlNumberPayer claim control numberStringREF02 *F8
payerPayerPartyNM1 *PR
Loop: 2330B
providersOther payer's providersList of PartyNM1

Person with Demographic Info

NameDescriptionTypeEDI Element
entityRoleEntity role
View codes and descriptions
StringNM101, N101
entityTypeEntity typeStringNM102
identificationTypeIdentification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)StringNM108, N103
identifierIdentifierStringNM109, N104
lastNameOrOrgNameOrganization name or person last nameStringNM103, N102
firstNameFirst nameStringNM104
middleNameMiddle nameStringNM105
birthDateBirth dateDateDMG02
genderGenderStringDMG03
addressAddressAddress
contactsContactsList of ContactInfo
additionalIdsOther identificationsList of ReferenceREF

Organization or Person (Party)

NameDescriptionTypeEDI Element
entityRoleEntity role
View codes and descriptions
StringNM101, N101
entityTypeEntity typeStringNM102
identificationTypeIdentification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)StringNM108, N103
identifierIdentifierStringNM109, N104
lastNameOrOrgNameOrganization name or person last nameStringNM103, N102
firstNameFirst nameStringNM104
middleNameMiddle nameStringNM105
addressAddressAddress
providerTaxonomyProvider's specialty information (taxonomy). Populated only for billing, rendering, operating providers.
View codes and descriptions
CodePRV
contactsContactsList of ContactInfo
additionalIdsOther identificationsList of ReferenceREF

Contact Info

Segment: PER Open API Schema
NameDescriptionTypeEDI Element
nameNameStringPER02
contactNumbersContact numbersList of ContactNumber

Contact Number

Segment: PER Open API Schema
NameDescriptionTypeEDI Element
typeType of contact number, such as PHONE, EMAIL, URLStringPER03,PER05,PER07
numberNumberStringPER04,PER06,PER08

Adjudication

Loop: 2430, Segment: SVD Open API Schema
NameDescriptionTypeEDI Element
payerIdentifierPayer identifierStringSVD01
paidAmountPaid amountNumberSVD02
unitCountUnit countNumberSVD05
bundledOrUnbundledLineNumberBundled or unbundled line numberIntegerSVD06
procedureProcedure
View codes and descriptions
ProcedureSVD03
adjustmentsLine adjustmentsList of AdjustmentCAS
adjudicationOrPaymentDateAdjudication or payment dateDateDTP03 *573
remainingPatientLiabilityAmountRemaining patient liability amountNumberAMT02 *EAF

Adjustment

Segment: CAS Open API Schema
NameDescriptionTypeEDI Element
groupClaim adjustment group code as a string constant (enum)StringCAS01
reasonCodeClaim adjustment reason code
View codes and descriptions
StringCAS02
amountAdjustment amountNumberCAS03
quantityAdjustment quantityNumberCAS04

Procedure

Procedure code with description and optional modifiers
Segment: HI,SV1,SV2,SV3,SVC Open API Schema
NameDescriptionTypeEDI Element
codeHealthcare codeString
descCode description String
modifiersModifiersList of Code837P:SV101-3-6, 837I:SV201-3-6, 835:SVC01-3-6, 277:SVC01-3-6

Code

Code and description
NameDescriptionTypeEDI Element
codeHealthcare codeString
descCode description String

EDI Transaction Info

NameDescriptionTypeEDI Element
controlNumberControl numberStringST02
transactionTypeTransaction type translated to string constant, PROF for 837P, INST for 837I, etc.StringST01,ST03
purposeCodePurpose codeStringBHT02
originatorApplicationTransactionIdOriginator application transaction idStringBHT03
creationDateCreation dateDateBHT04
creationTimeCreation timeTimeBHT05
claimOrEncounterIdentifierTypeClaim or encounter identifier typeStringBHT06
transactionSetIdentifierCodeTransaction set identifier codeStringST01
implementationConventionReferenceImplementation convention referenceStringST03
senderSubmitter or sender of this transactionPartyIdName
receiverReceiver of this transactionPartyIdName

Organization Or Person ID and Name

NameDescriptionTypeEDI Element
entityRoleEntity role
View codes and descriptions
StringNM101, N101
entityTypeType of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for personStringNM102
identificationTypeIdentification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)StringNM108, N103
identifierIdentifierStringNM109, N104
lastNameOrOrgNameOrganization name or person last nameStringNM103, N102
firstNameFirst nameStringNM104
middleNameMiddle nameStringNM105