JSON Schema for 837D (Dental Claim)

Unique payment identifier assigned by the converter

Type of this object, set to 'CLAIM'

Identifier used to track a claim from creation by the health care provider through payment

Charge amount

Patient paid amount

Place of service code (professional/dental) or UB facility code (institutional) from the original claim

View codes and descriptions

Frequency code

View codes and descriptions

The earliest service date from service lines

The latest service date from service lines

The insured (subscriber)

Patient if different from the the insured (subscriber)

Other subscribers and their payer's information

Service lines

Parent EDI transaction for this object

Provider signature indicator

Assignment participation code

Assignment certification indicator

Release of information code

Related cause

Special program code

Delay reason code

Service authorization exception code

Referral number

Prior authorization number

Original reference number

Repriced reference number

Adjusted repriced reference number

Clearinghouse trace number

Medical record number

Demonstration project identifier

Accident date

Orthodontic banding date

Repricer received date

Orthodontic info

Tooth statuses

Predetermination of benefits identifier

Fixed format records

Free-form comments or instructions. All note segments are concatenated together into this field

Billing provider

Pay to address

Pay-to plan for subrogation claims

Providers for this claim, except for the billing provider

Attachments

Contract info

Treatment months count

Treatment months remaining count

Treatment indicator

Tooth number

Status code

Line item control number

Oral cavity designation codes

Prosthesis crown or inlay code

Predetermination of benefits identifier

Repriced reference number

Adjusted repriced reference number

Prior authorization

Referral number

Charge amount

Sales tax amount

Service date from

Service date to

Prior placement date

Orthodontic banding date

Replacement date

Treatment start date

Treatment completion date

Unit count

Procedure

View codes and descriptions

Attachments

Contract info

Providers for this service line

Adjudications

Copy of line adjustments from the adjudication list for backward compatibility

Fixed format records

Tooth infos

Diagnosis pointers. Each pointer is an index of the diagnosis in the 'diags' array at the claim level.

Copy of diagnosis codes from the claim based on diagnosis pointers

View codes and descriptions

Code

Surface codes

Payer responsibility sequence

Values:

EIGHT(E), ELEVEN(H), FIVE(B), FOUR(A), NINE(F), PRIMARY(P), SECONDARY(S), SEVEN(D), SIX(C), TEN(G), TERTIARY(T), UNCONFIRMED(N), UNKNOWN(U)

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

Group or policy number

Group name

Claim filing indicator code

Insurance plan type

Values:

AUTOMOBILE_MEDICAL(AM), BCBS(BL), CHAMPUS(CH), COMMERCIAL(CI), EPO(14), FEDERAL_EMPLOYEE_PROGRAM(FI), HMO(HM), HMO_MEDICARE(16), INDEMNITY_INSURANCE(15), MEDICAID(MC), MEDICARE_A(MA), MEDICARE_B(MB), MUTUALLY_DEFINED(ZZ), OTHER_FEDERAL(OF), OTHER_NON_FEDERAL(11), POS(13), PPO(12), VETERAN_AFFAIRS(VA), WORKERS_COMPENSATION(WC)

Person

Death date

Patient weight in pounds

Pregnancy indicator

Property casualty claim number

Payer

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

Person

Death date

Patient weight in pounds

Pregnancy indicator

Payer responsibility sequence

Values:

EIGHT(E), ELEVEN(H), FIVE(B), FOUR(A), NINE(F), PRIMARY(P), SECONDARY(S), SEVEN(D), SIX(C), TEN(G), TERTIARY(T), UNCONFIRMED(N), UNKNOWN(U)

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

Group or policy number

Group name

Coordination of benefits code, post-adjudicated claims only

Claim filing indicator code

Insurance plan type

Values:

AUTOMOBILE_MEDICAL(AM), BCBS(BL), CHAMPUS(CH), COMMERCIAL(CI), EPO(14), FEDERAL_EMPLOYEE_PROGRAM(FI), HMO(HM), HMO_MEDICARE(16), INDEMNITY_INSURANCE(15), MEDICAID(MC), MEDICARE_A(MA), MEDICARE_B(MB), MUTUALLY_DEFINED(ZZ), OTHER_FEDERAL(OF), OTHER_NON_FEDERAL(11), POS(13), PPO(12), VETERAN_AFFAIRS(VA), WORKERS_COMPENSATION(WC)

Person

Claim-level adjustments from this payer

Payer paid amount

Non covered amount

Remaining patient liability amount

Outpatient adjudication

Payer prior authorization number

Payer referral number

Payer claim control number

Payer

Patient's information; post-adjudicated claims only

Other payer's providers

Reimbursement rate

Claim HCPCS Payable Amount

Esrd payment amount

Nonpayable Professional Component Amount

Remark codes

View codes and descriptions

Entity role

View codes and descriptions

Type of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for person

Values:

BUSINESS(2), INDIVIDUAL(1)

Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)

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Identifier

Tax id

Organization name or person last name

First name

Middle name

Address

Contacts

Other identifications

Provider's specialty information (taxonomy). Populated only for billing, rendering, operating providers.

View codes and descriptions

Birth date

Gender

Values:

FEMALE(F), MALE(M), UNKNOWN(U)

Function code

Name

Contact numbers

Type of contact number

Values:

ALTERNATE_PHONE, BEEPER, CELL_PHONE, EMAIL, EXTENSION, FAX, HOME_PHONE, PHONE, UNKNOWN, URL, WORK_PHONE

Number

Related cause code

Related cause code2

State code

Country code

Payer identifier

Paid amount

Unit count

Bundled or unbundled line number

Procedure

View codes and descriptions

Line adjustments

Adjudication or payment date

Remaining patient liability amount

Claim adjustment group code as a string constant

Values:

CONTRACTUAL(CO), CORRECTION(CR), OTHER(OA), PATIENT_RESPONSIBILITY(PR), PAYOR_INITIATED(PI)

Claim adjustment reason code

View codes and descriptions

Adjustment amount

Adjustment quantity

Report type code

Report transmission code

Control number

Contract type code

Amount

Percentage

Contract code

Term discount percentage

Version identifier

Modifiers

Healthcare code subtype, such as CPT, HCPCS, ICD_10, NDC

Healthcare code

Code description

Control number

Transaction type translated to string constant, PROF for 837P, INST for 837I, etc.

Hierarchical structure code

Purpose code

Originator application transaction id

Creation date

Creation time

Claim or encounter identifier type

Transaction set identifier code

Implementation convention reference

File info

Submitter or sender of this transaction

Receiver of this transaction

Entity role

View codes and descriptions

Type of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for person

Values:

BUSINESS(2), INDIVIDUAL(1)

Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)

View codes and descriptions

Identifier

Tax id

Organization name or person last name

First name

Middle name

File name

URL of the file, including the full path

Last modified date and time of the file