837D Dental Claim Schema

Claim

Loop: 2300, Segment: CLM JSON Example

Name	Description	Type	EDI Element
id	Unique payment identifier assigned by the converter	String
objectType	Type of this object, set to 'CLAIM'	String
patientControlNumber	Identifier used to track a claim from creation by the health care provider through payment	String	CLM01
chargeAmount	Charge amount	Number	CLM02
patientPaidAmount	Patient paid amount	Number	AMT02 *F5
facilityCode	Place of service code (professional/dental) or UB facility code (institutional) from the original claim View codes and descriptions	Code	CLM05-1
frequencyCode	Frequency code View codes and descriptions	Code	CLM05-3
serviceDateFrom	The earliest service date from service lines	Date
serviceDateTo	The latest service date from service lines	Date
subscriber	The insured (subscriber)	Subscriber	Loop: 2000B
patient	Patient if different from the the insured (subscriber)	Patient	Loop: 2110CA
otherSubscribers	Other subscribers and their payer's information	List of OtherSubscriber	Loop: 2320
serviceLines	Service lines	List of ServiceLine	Loop: 2400
transaction	Parent EDI transaction for this object	Transaction
providerSignatureIndicator	Provider signature indicator	String	CLM06
assignmentParticipationCode	Assignment participation code	String	CLM07
assignmentCertificationIndicator	Assignment certification indicator	String	CLM08
releaseOfInformationCode	Release of information code	String	CLM09
specialProgramCode	Special program code	String	CLM12
delayReasonCode	Delay reason code	String	CLM20
referralNumber	Referral number	String	REF02 *9F
priorAuthorizationNumber	Prior authorization number	String	REF02 *G1
repricedReferenceNumber	Repriced reference number	String	REF02 *9A
adjustedRepricedReferenceNumber	Adjusted repriced reference number	String	REF02 *9C
medicalRecordNumber	Medical record number	String	REF02 *EA
accidentDate	Accident date	Date	DTP03 *439
orthodonticBandingDate	Orthodontic banding date	Date	DTP03 *452
repricerReceivedDate	Repricer received date	Date	DTP03 *050
orthodonticInfo	Orthodontic info	OrthodonticInfo
toothStatuses	Tooth statuses	List of ToothStatus
clearinghouseTraceNumber	Clearinghouse trace number	String	REF02 *D9
originalReferenceNumber	Original reference number	String	REF02 *F8
serviceAuthorizationExceptionCode	Service authorization exception code	String	REF02 *4N
predeterminationOfBenefitsIdentifier	Predetermination of benefits identifier	String	REF02 *G3
fixedFormatRecords	Fixed format records	List of String	K301
claimNote	Free-form comments or instructions. All note segments are concatenated together into this field.	String	NTE02
billingProvider	Billing provider	Party	NM1 *85
providers	Providers for this claim, except for the billing provider	Party
diags	Diagnosis codes View codes and descriptions	List of Code
attachments	Attachments	List of Attachment	PWK

Orthodontic Info

Segment: DN1

Name	Description	Type	EDI Element
treatmentMonthsCount	Treatment months count	Number	DN101
treatmentMonthsRemainingCount	Treatment months remaining count	Number	DN102
treatmentIndicator	Treatment indicator	String	DN104

Tooth Status

Segment: DN2

Name	Description	Type	EDI Element
toothNumber	Tooth number	String	DN201
statusCode	Status code	String	DN202

Service Line

Loop: 2400, Segment: SV3

Name	Description	Type	EDI Element
sourceLineId	Source line id	String	REF02 *6R
copayStatusCode	Copay status code	String	SV115
oralCavityDesignationCodes	Oral cavity designation codes	List	SV304
prosthesisCrownOrInlayCode	Prosthesis crown or inlay code	String	SV305
predeterminationOfBenefitsIdentifier	Predetermination of benefits identifier	String	REF02 *G3
repricedReferenceNumber	Repriced reference number	String	REF02 *9A
adjustedRepricedReferenceNumber	Adjusted repriced reference number	String	REF02 *9D
priorAuthorization	Prior authorization	String	REF02 *G1
referralNumber	Referral number	String	REF02 *9F
chargeAmount	Charge amount	Number	SV302
salesTaxAmount	Sales tax amount	Number	AMT02 *T
priorPlacementDate	Prior placement date	Date	DTP03 441, DTP03 139
orthodonticBandingDate	Orthodontic banding date	Date	DTP03 *452
replacementDate	Replacement date	Date	DTP03 *446
treatmentStartDate	Treatment start date	Date	DTP03 *196
treatmentCompletionDate	Treatment completion date	Date	DTP03 *198
unitType	Unit type	String	SV304
unitCount	Unit count	Number	SV305
procedure	Procedure View codes and descriptions	Procedure	SV302 HC, SV302 AD, SV302 WK, SV302 IV
attachments	Attachments	List of Attachment	PWK
providers	Providers for this service line	Party
adjudications	Adjudications	List of Adjudication	SVD Loop: 2430
adjustments	Copy of line adjustments from the adjudication list for backward compatibility	List of Adjustment	CAS
fixedFormatRecords	Fixed format records	List	K301
toothInfos	Tooth infos	List of ToothInfo

Tooth Info

Segment: TOO

Name	Description	Type	EDI Element
code	Code	String	TOO02
surfaceCodes	Surface codes	List of String	TOO03

Subscriber

Name	Description	Type	EDI Element
payerResponsibilitySequence	Payer responsibility sequence	String	SBR01
relationshipType	Relationship type	String	SBR02
groupOrPolicyNumber	Group or policy number	String	SBR03
groupName	Group name	String	SBR04
claimFilingIndicatorCode	Claim filing indicator code	String	SBR09
insurancePlanType	Insurance plan type	String	SBR09
person	Person	PersonWithDemographic	NM1
deathDate	Death date	Date	PAT06
weight	Patient weight in pounds	Number	PAT09
pregnancyIndicator	Pregnancy indicator	String	PAT09
propertyCasualtyClaimNumber	Property casualty claim number	String	REF02 *Y4
payer	Payer	Party	NM1 *PR Loop: 2330B

Patient

Name	Description	Type	EDI Element
person	Person	PersonWithDemographic	NM1
deathDate	Death date	Date	PAT06
weight	Patient weight in pounds	Number	PAT09
pregnancyIndicator	Pregnancy indicator	String	PAT09

Other Subscriber

Name	Description	Type	EDI Element
payerResponsibilitySequence	Payer responsibility sequence	String	SBR01
relationshipType	Relationship type	String	SBR02
groupOrPolicyNumber	Group or policy number	String	SBR03
groupName	Group name	String	SBR04
claimFilingIndicatorCode	Claim filing indicator code	String	SBR09
insurancePlanType	Insurance plan type	String	SBR09
person	Person	PersonWithDemographic	NM1
pregnancyIndicator	Pregnancy indicator	String	PAT09
adjustments	Claim-level adjustments from this payer	List of Adjustment	CAS
payerPaidAmount	Payer paid amount	Number	AMT02 *D
nonCoveredAmount	Non covered amount	Number	AMT02 *A8
remainingPatientLiabilityAmount	Remaining patient liability amount	Number	AMT02 *EAF
payerPriorAuthorizationNumber	Payer prior authorization number	String	REF02 *G1
payerReferralNumber	Payer referral number	String	REF02 *9F
payerClaimControlNumber	Payer claim control number	String	REF02 *F8
payer	Payer	Party	NM1 *PR Loop: 2330B
providers	Other payer's providers	List of Party	NM1

Person with Demographic Info

Name	Description	Type	EDI Element
entityRole	Entity role View codes and descriptions	String	NM102, N101
entityType	Entity type	String	NM102
identificationType	Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)	String	NM108, N103
identifier	Identifier	String	NM109, N104
lastNameOrOrgName	Organization name or person last name	String	NM103, N102
firstName	First name	String	NM104
middleName	Middle name	String	NM105
birthDate	Birth date	Date	DMG02
gender	Gender	String	DMG03
address	Address	Address
contacts	Contacts	List of Contact
additionalIds	Other identifications	List of Reference	REF

Organization or Person (Party)

Name	Description	Type	EDI Element
entityRole	Entity role View codes and descriptions	String	NM102, N101
entityType	Entity type	String	NM102
identificationType	Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)	String	NM108, N103
identifier	Identifier	String	NM109, N104
lastNameOrOrgName	Organization name or person last name	String	NM103, N102
firstName	First name	String	NM104
middleName	Middle name	String	NM105
address	Address	Address
providerTaxonomy	Provider's specialty information (taxonomy). Populated only for billing, rendering, operating providers. View codes and descriptions	Code	PRV
contacts	Contacts	List of Contact
additionalIds	Other identifications	List of Reference	REF

Contact

Segment: PER

Name	Description	Type	EDI Element
name	Name	String	PER02
contactNumbers	Contact numbers	List of ContactNumber

Contact Number

Segment: PER

Name	Description	Type	EDI Element
type	Type	String	PER03,PER05,PER07
number	Number	String	PER04,PER06,PER08

Adjudication

Loop: 2430, Segment: SVD

Name	Description	Type	EDI Element
payerIdentifier	Payer identifier	String	SVD01
paidAmount	Paid amount	Number	SVD02
unitCount	Unit count	Number	SVD05
bundledOrUnbundledLineNumber	Bundled or unbundled line number	Integer	SVD06
procedure	Procedure View codes and descriptions	Procedure	SVD03
adjustments	Line adjustments	List of Adjustment	CAS
adjudicationOrPaymentDate	Adjudication or payment date	Date	DTP03 *573
remainingPatientLiabilityAmount	Remaining patient liability amount	Number	AMT02 *EAF

Adjustment

Segment: CAS

Name	Description	Type	EDI Element
group	Claim adjustment group code as a string constant (enum)	String	CAS01
reasonCode	Claim adjustment reason code View codes and descriptions	String	CAS02
amount	Adjustment amount	Number	CAS03
quantity	Adjustment quantity	Number	CAS04

Procedure

Procedure code with description and optional modifiers

Segment: HI,SV1,SV2,SVC

Name	Description	Type	EDI Element
code	Healthcare code	String
desc	Code description	String
modifiers	Modifiers	List of Code	837P:SV101-3-6, 837I:SV201-3-6, 835:SVC01-3-6

Code

Code and description

Name	Description	Type	EDI Element
code	Healthcare code	String
desc	Code description	String

EDI Transaction Info

Name	Description	Type	EDI Element
controlNumber	Control number	String	ST02
transactionType	Transaction type translated to string constant, PROF for 837P, INST for 837I, etc.	String	ST01,ST03
purposeCode	Purpose code	String	BHT02
originatorApplicationTransactionId	Originator application transaction id	String	BHT03
creationDate	Creation date	Date	BHT04
creationTime	Creation time	Time	BHT05
claimOrEncounterIdentifierType	Claim or encounter identifier type	String	BHT06
originalTransactionSetReferenceNumber	Original transaction set reference number	String	BGN06
actionCode	Action code	String	BGN08
transactionSetIdentifierCode	Transaction set identifier code	String	ST01
implementationConventionReference	Implementation convention reference	String	ST03