Appendix E - Data Element Glossary

Data Element Name Index

This section contains an alphabetic listing of data elements used in this implementation guide. Consult the X12N Data Element Dictionary for a complete list of all X12N Data Elements. Data element names in normal type are generic ASC X12 names. Italic type indicates a health care industry defined name.

Legend

Industry Name
Industry name definition.
800 - Transaction Set ID and Name
H=Header, D=Detail, S=Summary | Loop ID | Reference Designator | Composite ID-Position in Composite | X12 Data Element Number
 
Accident Date
Date of the accident related to charges or to the patient's current condition, diagnosis, or treatment referenced in the transaction.
837 - Health Care Claim Dental
D | 2300 | DTP03 | - | 1251
 
Adjusted Repriced Claim Reference Number
Identification number, assigned by a repricing organization, to identify an adjusted claim.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
 
Adjusted Repriced Line Item Reference Number
Identification number of an adjusted repriced line item adjusted from an original amount.
837 - Health Care Claim Dental
D | 2400 | REF02 | - | 127
 
Adjustment Amount
Adjustment amount for the associated reason code.
837 - Health Care Claim Dental
D | 2320 | RAS01 | - | 782
D | 2430 | RAS01 | - | 782
 
Adjustment Quantity
Numeric quantity associated with the related reason code for coordination of benefits.
837 - Health Care Claim Dental
D | 2430 | RAS04 | - | 380
 
Adjustment Reason Code
Code that indicates the reason for the adjustment.
837 - Health Care Claim Dental
D | 2320 | RAS03 | C058-01 | 1034
D | 2430 | RAS03 | C058-01 | 1034
 
Amount Qualifier Code
Code to qualify amount.
837 - Health Care Claim Dental
D | 2300 | AMT01 | - | 522
D | 2320 | AMT01 | - | 522
D | 2320 | AMT01 | - | 522
D | 2320 | AMT01 | - | 522
D | 2320 | AMT01 | - | 522
D | 2400 | AMT01 | - | 522
D | 2430 | AMT01 | - | 522
D | 2430 | AMT01 | - | 522
 
Assigned Number
Number assigned for differentiation within a transaction set.
837 - Health Care Claim Dental
D | 2400 | LX01 | - | 554
 
Assignment or Plan Participation Code
An indication, used by a health plan, that the provider does or does not accept assignment of benefits.
837 - Health Care Claim Dental
D | 2300 | CLM07 | - | 1359
 
Assistant Surgeon First Name
First name of the Assistant Surgeon
837 - Health Care Claim Dental
D | 2310D | NM104 | - | 1036
D | 2420B | NM104 | - | 1036
 
Assistant Surgeon Last Name
Last name of the Assistant Surgeon.
837 - Health Care Claim Dental
D | 2310D | NM103 | - | 1035
 
Assistant Surgeon Last or Organization Name
Lase name or organization name of the Assistant Surgeon
837 - Health Care Claim Dental
D | 2420B | NM103 | - | 1035
 
Assistant Surgeon Middle Name or Initial
Middle name or initial of the Assistant Surgeon.
837 - Health Care Claim Dental
D | 2310D | NM105 | - | 1037
D | 2420B | NM105 | - | 1037
 
Assistant Surgeon Name Suffix
Name suffix of the Assistant Surgeon
837 - Health Care Claim Dental
D | 2310D | NM107 | - | 1039
D | 2420B | NM107 | - | 1039
 
Assistant Surgeon Primary Identifier
Primary identification number of the Assistant Surgeon.
837 - Health Care Claim Dental
D | 2310D | NM109 | - | 67
D | 2420B | NM109 | - | 67
 
Assistant Surgeon Secondary Identifier
Additional identifier of the Assistant Surgeon
837 - Health Care Claim Dental
D | 2310D | REF02 | - | 127
D | 2420B | REF02 | - | 127
 
Attachment Control Number
Identification number of attachment related to the claim.
837 - Health Care Claim Dental
D | 2300 | PWK06 | - | 67
 
Attachment Report Type Code
Code to specify the type of attachment that is related to the claim.
837 - Health Care Claim Dental
D | 2300 | PWK01 | - | 755
 
Attachment Transmission Code
Code defining timing, transmission method or format by which an attachment report is to be sent or has been sent.
837 - Health Care Claim Dental
D | 2300 | PWK02 | - | 756
 
Auto Accident State or Province Code
State or Province where auto accident occurred.
837 - Health Care Claim Dental
D | 2300 | CLM11 | C024-04 | 156
 
Benefits Assignment Certification Indicator
A code showing whether the provider has a signed form authorizing the third party payer to pay the provider.
837 - Health Care Claim Dental
D | 2300 | CLM08 | - | 1073
D | 2320 | OI03 | - | 1073
 
Billing Provider Address Line
Address line of the billing provider or billing entity address.
837 - Health Care Claim Dental
D | 2010AA | N301 | - | 166
D | 2010AA | N302 | - | 166
 
Billing Provider City Name
City of the billing provider or billing entity
837 - Health Care Claim Dental
D | 2010AA | N401 | - | 19
 
Billing Provider Contact Name
Person at billing organization to contact regarding the billing transaction.
837 - Health Care Claim Dental
D | 2010AA | PER02 | - | 93
 
Billing Provider Country Code
Country code for the provider or billing entity billing for services.
837 - Health Care Claim Dental
D | 2010AA | N404 | - | 26
 
Billing Provider Country Subdivision Code
Country subdivision code for the provider or billing entity billing for services.
837 - Health Care Claim Dental
D | 2010AA | N407 | - | 1715
 
Billing Provider First Name
First name of the billing provider or billing entity
837 - Health Care Claim Dental
D | 2010AA | NM104 | - | 1036
 
Billing Provider Identifier
Identification number for the provider or organization in whose name the bill is submitted and to whom payment should be made.
837 - Health Care Claim Dental
D | 2010AA | NM109 | - | 67
 
Billing Provider Last or Organizational Name
Last name or organization name of the provider billing or billing entity for services.
837 - Health Care Claim Dental
D | 2010AA | NM103 | - | 1035
 
Billing Provider Middle Name or Initial
The middle name or initial of the provider billing for services.
837 - Health Care Claim Dental
D | 2010AA | NM105 | - | 1037
 
Billing Provider Name Suffix
Suffix, including generation, for the name of the provider or billing entity submitting the claim.
837 - Health Care Claim Dental
D | 2010AA | NM107 | - | 1039
 
Billing Provider Postal Zone or ZIP Code
Postal zone code or ZIP code for the provider or billing entity billing for services.
837 - Health Care Claim Dental
D | 2010AA | N403 | - | 116
 
Billing Provider Secondary Identifier
Secondary identification number for the provider or organization in whose name the bill is submitted and to whom payment should be made.
837 - Health Care Claim Dental
D | 2010BB | REF02 | - | 127
 
Billing Provider State or Province Code
State or province for provider or billing entity billing for services.
837 - Health Care Claim Dental
D | 2010AA | N402 | - | 156
 
Billing Provider Tax Identification Number
Tax identification number for the provider or organization in whose name the bill is submitted and to whom payment should be made.
837 - Health Care Claim Dental
D | 2010AA | REF02 | - | 127
 
Bundled Line Number
Identification of line item bundled by payer in payment of benefits.
837 - Health Care Claim Dental
D | 2430 | SVD06 | - | 554
 
Claim Adjustment Group Code
Code identifying the general category of payment adjustment.
837 - Health Care Claim Dental
D | 2320 | RAS02 | - | 1785
D | 2430 | RAS02 | - | 1785
 
Claim Allowed Amount
The amount the payer deems payable for this claim, prior to considering patient responsibility.
837 - Health Care Claim Dental
D | 2320 | AMT02 | - | 782
 
Claim Authorization Exception Code
Code identifying the reason for requesting an exception to standard processing of the claim.
837 - Health Care Claim Dental
D | 2300 | CLM21 | - | 1774
 
Claim Filing Indicator Code
Code identifying type of claim or expected adjudication process.
837 - Health Care Claim Dental
D | 2000B | SBR09 | - | 1032
D | 2320 | SBR09 | - | 1032
 
Claim Frequency Code
Code specifying the frequency of the claim. This is the third position of the Uniform Billing Claim Form Bill Type.
837 - Health Care Claim Dental
D | 2300 | CLM05 | C023-03 | 1325
 
Claim Note Text
Narrative text providing additional information related to the claim.
837 - Health Care Claim Dental
D | 2300 | NTE02 | - | 352
 
Claim or Encounter Identifier
Code indicating whether the transaction is a claim or reporting encounter information.
837 - Health Care Claim Dental
H | | BHT06 | - | 640
 
Code List Qualifier Code
Code identifying a specific industry code list.
837 - Health Care Claim Dental
D | 2300 | DN206 | - | 1270
D | 2300 | HI01 | C022-01 | 1270
D | 2300 | HI02 | C022-01 | 1270
D | 2300 | HI03 | C022-01 | 1270
D | 2300 | HI04 | C022-01 | 1270
D | 2300 | HI01 | C022-01 | 1270
D | 2300 | HI02 | C022-01 | 1270
D | 2300 | HI03 | C022-01 | 1270
D | 2300 | HI04 | C022-01 | 1270
D | 2320 | RAS03 | C058-02 | 1270
D | 2320 | LQ01 | - | 1270
D | 2400 | TOO01 | - | 1270
D | 2430 | RAS03 | C058-02 | 1270
D | 2430 | LQ01 | - | 1270
 
Communication Number
Complete communications number including country or area code when applicable
837 - Health Care Claim Dental
H | 1000A | PER04 | - | 364
H | 1000A | PER06 | - | 364
H | 1000A | PER08 | - | 364
D | 2010AA | PER04 | - | 364
D | 2010AA | PER06 | - | 364
D | 2010AA | PER08 | - | 364
D | 2010AD | PER04 | - | 364
D | 2010AD | PER06 | - | 364
D | 2010AD | PER08 | - | 364
D | 2010BA | PER04 | - | 364
D | 2010BA | PER06 | - | 364
D | 2010CA | PER04 | - | 364
D | 2010CA | PER06 | - | 364
 
Communication Number Qualifier
Code identifying the type of communication number.
837 - Health Care Claim Dental
H | 1000A | PER03 | - | 365
H | 1000A | PER05 | - | 365
H | 1000A | PER07 | - | 365
D | 2010AA | PER03 | - | 365
D | 2010AA | PER05 | - | 365
D | 2010AA | PER07 | - | 365
D | 2010AD | PER03 | - | 365
D | 2010AD | PER05 | - | 365
D | 2010AD | PER07 | - | 365
D | 2010BA | PER03 | - | 365
D | 2010BA | PER05 | - | 365
D | 2010CA | PER03 | - | 365
D | 2010CA | PER05 | - | 365
 
Condition Code
Code(s) used to identify condition(s) relating to this bill or relating to the patient.
837 - Health Care Claim Dental
D | 2300 | HI01 | C022-02 | 1271
D | 2300 | HI02 | C022-02 | 1271
D | 2300 | HI03 | C022-02 | 1271
D | 2300 | HI04 | C022-02 | 1271
 
Contact Function Code
Code identifying the major duty or responsibility of the person or group named.
837 - Health Care Claim Dental
H | 1000A | PER01 | - | 366
D | 2010AA | PER01 | - | 366
D | 2010AD | PER01 | - | 366
D | 2010BA | PER01 | - | 366
D | 2010CA | PER01 | - | 366
 
Contract Amount
Fixed monetary amount pertaining to the contract
837 - Health Care Claim Dental
D | 2300 | CN102 | - | 782
D | 2400 | CN102 | - | 782
 
Contract Code
Code identifying the specific contract, established by the payer.
837 - Health Care Claim Dental
D | 2300 | CN104 | - | 127
D | 2400 | CN104 | - | 127
 
Contract Percentage
Percent of charges payable under the contract
837 - Health Care Claim Dental
D | 2300 | CN103 | - | 332
D | 2400 | CN103 | - | 332
 
Contract Type Code
Code identifying a contract type
837 - Health Care Claim Dental
D | 2300 | CN101 | - | 1166
D | 2400 | CN101 | - | 1166
 
Contract Version Identifier
Identification of additional or supplemental contract provisions, or identification of a particular version or modification of contract.
837 - Health Care Claim Dental
D | 2300 | CN106 | - | 799
D | 2400 | CN106 | - | 799
 
Country Code
Code indicating the geographic location.
837 - Health Care Claim Dental
D | 2300 | CLM11 | C024-05 | 26
 
Currency Code
Code for country in whose currency the charges are specified.
837 - Health Care Claim Dental
D | 2000A | CUR02 | - | 100
 
Date Time Period
Expression of a date, a time, or a range of dates, times, or dates and times.
837 - Health Care Claim Dental
D | 2300 | DTP03 | - | 1251
 
Date Time Period Format Qualifier
Code indicating the date format, time format, or date and time format.
837 - Health Care Claim Dental
D | 2010BA | DMG01 | - | 1250
D | 2010CA | DMG01 | - | 1250
D | 2300 | DTP02 | - | 1250
D | 2300 | DTP02 | - | 1250
D | 2300 | DTP02 | - | 1250
D | 2300 | DTP02 | - | 1250
D | 2300 | DTP02 | - | 1250
D | 2330B | DTP02 | - | 1250
D | 2400 | DTP02 | - | 1250
D | 2400 | DTP02 | - | 1250
D | 2400 | DTP02 | - | 1250
D | 2400 | DTP02 | - | 1250
D | 2430 | DTP02 | - | 1250
 
Date Time Qualifier
Code specifying the type of date or time or both date and time.
837 - Health Care Claim Dental
D | 2300 | DTP01 | - | 374
D | 2300 | DTP01 | - | 374
D | 2300 | DTP01 | - | 374
D | 2300 | DTP01 | - | 374
D | 2300 | DTP01 | - | 374
D | 2330B | DTP01 | - | 374
D | 2400 | DTP01 | - | 374
D | 2400 | DTP01 | - | 374
D | 2400 | DTP01 | - | 374
D | 2400 | DTP01 | - | 374
D | 2430 | DTP01 | - | 374
 
Delay Reason Code
Code indicating the reason why a request was delayed.
837 - Health Care Claim Dental
D | 2300 | CLM20 | - | 1514
 
Dental Readiness Code
Used to reflect the active duty service member's (ADSM) oral health and to determine if the ADSM is dentally ready to deploy for worldwide duty.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
 
Diagnosis Code
An ICD-9-CM Diagnosis Code identifying a diagnosed medical condition.
837 - Health Care Claim Dental
D | 2300 | HI01 | C022-02 | 1271
D | 2300 | HI02 | C022-02 | 1271
D | 2300 | HI03 | C022-02 | 1271
D | 2300 | HI04 | C022-02 | 1271
 
Diagnosis Code Pointer
A pointer to the claim diagnosis code in the order of importance to this service.
837 - Health Care Claim Dental
D | 2400 | SV311 | - | 1328
 
Entity Identifier Code
Code identifying an organizational entity, a physical location, property or an individual.
837 - Health Care Claim Dental
H | 1000A | NM101 | - | 98
H | 1000B | NM101 | - | 98
D | 2000A | CUR01 | - | 98
D | 2010AA | NM101 | - | 98
D | 2010AB | NM101 | - | 98
D | 2010AC | NM101 | - | 98
D | 2010AD | NM101 | - | 98
D | 2010BA | NM101 | - | 98
D | 2010BB | NM101 | - | 98
D | 2010CA | NM101 | - | 98
D | 2310A | NM101 | - | 98
D | 2310B | NM101 | - | 98
D | 2310C | NM101 | - | 98
D | 2310D | NM101 | - | 98
D | 2310E | NM101 | - | 98
D | 2330A | NM101 | - | 98
D | 2330B | NM101 | - | 98
D | 2330C | NM101 | - | 98
D | 2330D | NM101 | - | 98
D | 2330E | NM101 | - | 98
D | 2330F | NM101 | - | 98
D | 2330G | NM101 | - | 98
D | 2420A | NM101 | - | 98
D | 2420B | NM101 | - | 98
D | 2420C | NM101 | - | 98
D | 2420D | NM101 | - | 98
 
Entity Type Qualifier
Code qualifying the type of entity.
837 - Health Care Claim Dental
H | 1000A | NM102 | - | 1065
H | 1000B | NM102 | - | 1065
D | 2010AA | NM102 | - | 1065
D | 2010AB | NM102 | - | 1065
D | 2010AC | NM102 | - | 1065
D | 2010AD | NM102 | - | 1065
D | 2010BA | NM102 | - | 1065
D | 2010BB | NM102 | - | 1065
D | 2010CA | NM102 | - | 1065
D | 2310A | NM102 | - | 1065
D | 2310B | NM102 | - | 1065
D | 2310C | NM102 | - | 1065
D | 2310D | NM102 | - | 1065
D | 2310E | NM102 | - | 1065
D | 2330A | NM102 | - | 1065
D | 2330B | NM102 | - | 1065
D | 2330C | NM102 | - | 1065
D | 2330D | NM102 | - | 1065
D | 2330E | NM102 | - | 1065
D | 2330F | NM102 | - | 1065
D | 2330G | NM102 | - | 1065
D | 2420A | NM102 | - | 1065
D | 2420B | NM102 | - | 1065
D | 2420C | NM102 | - | 1065
D | 2420D | NM102 | - | 1065
 
Exception Code
Exception code generated by the Third Party Organization.
837 - Health Care Claim Dental
D | 2300 | HCP15 | - | 1527
D | 2400 | HCP15 | - | 1527
 
Facility Code Qualifier
Code identifying the type of facility referenced.
837 - Health Care Claim Dental
D | 2300 | CLM05 | C023-02 | 1332
 
HCPCS Payable Amount
Amount due under Medicare HCPCS system.
837 - Health Care Claim Dental
D | 2320 | MOA02 | - | 782
 
Hierarchical Child Code
Code indicating if there are hierarchical child data segments subordinate to the level being described.
837 - Health Care Claim Dental
D | 2000A | HL04 | - | 736
D | 2000B | HL04 | - | 736
D | 2000C | HL04 | - | 736
 
Hierarchical ID Number
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure.
837 - Health Care Claim Dental
D | 2000A | HL01 | - | 628
D | 2000B | HL01 | - | 628
D | 2000C | HL01 | - | 628
 
Hierarchical Level Code
Code defining the characteristic of a level in a hierarchical structure.
837 - Health Care Claim Dental
D | 2000A | HL03 | - | 735
D | 2000B | HL03 | - | 735
D | 2000C | HL03 | - | 735
 
Hierarchical Parent ID Number
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to.
837 - Health Care Claim Dental
D | 2000B | HL02 | - | 734
D | 2000C | HL02 | - | 734
 
Hierarchical Structure Code
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
837 - Health Care Claim Dental
H | | BHT01 | - | 1005
 
Identification Code Qualifier
Code designating the system/method of code structure used for Identification Code (67).
837 - Health Care Claim Dental
H | 1000A | NM108 | - | 66
H | 1000B | NM108 | - | 66
D | 2010AA | NM108 | - | 66
D | 2010AC | NM108 | - | 66
D | 2010AD | NM108 | - | 66
D | 2010BA | NM108 | - | 66
D | 2010BB | NM108 | - | 66
D | 2300 | PWK05 | - | 66
D | 2310A | NM108 | - | 66
D | 2310B | NM108 | - | 66
D | 2310C | NM108 | - | 66
D | 2310D | NM108 | - | 66
D | 2310E | NM108 | - | 66
D | 2330A | NM108 | - | 66
D | 2330B | NM108 | - | 66
D | 2420A | NM108 | - | 66
D | 2420B | NM108 | - | 66
D | 2420C | NM108 | - | 66
D | 2420D | NM108 | - | 66
 
Implementation Guide Version Name
Name of the referenced implementation guide version.
837 - Health Care Claim Dental
H | | ST03 | - | 1705
 
Individual Relationship Code
Code indicating the relationship between two individuals or entities.
837 - Health Care Claim Dental
D | 2000B | SBR02 | - | 1069
D | 2000C | PAT01 | - | 1069
D | 2320 | SBR02 | - | 1069
 
Insured Group or Policy Number
The identification number, control number, or code assigned by the carrier or administrator to identify the group under which the individual is covered.
837 - Health Care Claim Dental
D | 2320 | SBR03 | - | 127
 
Laboratory or Facility Primary Identifier
Identification number of laboratory or other facility performing laboratory testing on the claim where the health care service was performed/rendered.
837 - Health Care Claim Dental
D | 2310C | NM109 | - | 67
 
Line Item Charge Amount
Charges related to this service.
837 - Health Care Claim Dental
D | 2400 | SV302 | - | 782
 
Line Item Control Number
Identifier assigned by the submitter/provider to this line item.
837 - Health Care Claim Dental
D | 2400 | REF02 | - | 127
 
Medicare Assignment Code
An indication, used by Medicare or other government programs, that the provider accepted assignment.
837 - Health Care Claim Dental
D | 2320 | OI07 | - | 1359
 
Name
Free-form name.
837 - Health Care Claim Dental
D | 2010BA | PER02 | - | 93
 
Non-Covered Charge Amount
Charges pertaining to the related revenue center code that the primary payer will not cover.
837 - Health Care Claim Dental
D | 2320 | AMT02 | - | 782
 
Non-Payable Professional Component Billed Amount
Amount of non-payable charges included in the bill related to professional services.
837 - Health Care Claim Dental
D | 2320 | MOA09 | - | 782
 
Note Reference Code
Code identifying the functional area or purpose for which the note applies.
837 - Health Care Claim Dental
D | 2300 | NTE01 | - | 363
 
Oral Cavity Designation Code
Code identifying an oral cavity involved in the service.
837 - Health Care Claim Dental
D | 2400 | SV304 | C006-01 | 1361
D | 2400 | SV304 | C006-02 | 1361
D | 2400 | SV304 | C006-03 | 1361
D | 2400 | SV304 | C006-04 | 1361
D | 2400 | SV304 | C006-05 | 1361
 
Originator Application Transaction Identifier
An identification number that identifies a transaction within the originator's applications system.
837 - Health Care Claim Dental
H | | BHT03 | - | 127
 
Orthodontic Banding Date
Date that Orthodontic bands were applied.
837 - Health Care Claim Dental
D | 2300 | DTP03 | - | 1251
D | 2400 | DTP03 | - | 1251
 
Orthodontic Treatment Indicator
Code indicating that reported treatment was for orthodontic purposes.
837 - Health Care Claim Dental
D | 2300 | DN104 | - | 352
 
Orthodontic Treatment Months Count
Estimated Number of Treatment Months for Orthodontic Treatment
837 - Health Care Claim Dental
D | 2300 | DN101 | - | 380
 
Orthodontic Treatment Months Remaining Count
Number of Treatment Months Remaining for Orthodontic Treatment
837 - Health Care Claim Dental
D | 2300 | DN102 | - | 380
 
Other Insured Group Name
Name of the group or plan through which the insurance is provided to the other insured.
837 - Health Care Claim Dental
D | 2320 | SBR04 | - | 93
 
Other Payer Address Line
Address line of the other payer's mailing address.
837 - Health Care Claim Dental
D | 2330B | N301 | - | 166
D | 2330B | N302 | - | 166
 
Other Payer Assistant Surgeon Secondary Identifier
Additional identifier for the Assistant Surgeon.
837 - Health Care Claim Dental
D | 2330G | REF02 | - | 127
 
Other Payer Billing Provider Identifier
The non-destination (COB) payer's identifier for the provider or organization in whose name the bill is submitted and to whom payment should be made.
837 - Health Care Claim Dental
D | 2330E | REF02 | - | 127
 
Other Payer City Name
The city name of the other payer's mailing address.
837 - Health Care Claim Dental
D | 2330B | N401 | - | 19
 
Other Payer Claim Adjustment Indicator
Indicates this claim has been adjusted.
837 - Health Care Claim Dental
D | 2320 | OI08 | - | 1073
 
Other Payer Country Code
Code indicating the geographic location of the other payer.
837 - Health Care Claim Dental
D | 2330B | N404 | - | 26
 
Other Payer Country Subdivision Code
Subdivision code indicating the geographic location of the other payer.
837 - Health Care Claim Dental
D | 2330B | N407 | - | 1715
 
Other Payer Organization Name
Organization name of this non-destination (COB) payer.
837 - Health Care Claim Dental
D | 2330B | NM103 | - | 1035
 
Other Payer Postal Zone or ZIP Code
The ZIP code of the other payer's mailing address.
837 - Health Care Claim Dental
D | 2330B | N403 | - | 116
 
Other Payer Predetermination of Benefits Identifier
The non-destination (COB) payer's identification number assigned to a Predetermination of Benefits.
837 - Health Care Claim Dental
D | 2330B | REF02 | - | 127
 
Other Payer Previous Claim Control Number
A number assigned by another payer to identify a previously adjusted claim. The number may also be identified as an Internal Control Number (ICN), Claim Control Number (CCN) or Document Control Number (DCN).
837 - Health Care Claim Dental
D | 2330B | REF02 | - | 127
 
Other Payer Primary Identifier
An identification number for the other payer.
837 - Health Care Claim Dental
D | 2330B | NM109 | - | 67
 
Other Payer Prior Authorization Number
The non-destination (COB) payer's prior authorization number.
837 - Health Care Claim Dental
D | 2330B | REF02 | - | 127
 
Other Payer Referral Number
The non-destination (COB) payer's referral number.
837 - Health Care Claim Dental
D | 2330B | REF02 | - | 127
 
Other Payer Referring Provider Secondary Identifier
The non-destination (COB) payer's referring provider identifier.
837 - Health Care Claim Dental
D | 2330C | REF02 | - | 127
 
Other Payer Rendering Provider Secondary Identifier
The non-destination (COB) payer's rendering provider identifier.
837 - Health Care Claim Dental
D | 2330D | REF02 | - | 127
 
Other Payer Responsibility Sequence Code
Code indicating the order in which benefits will be adjudicated when multiple payers are involved.
837 - Health Care Claim Dental
D | 2320 | SBR01 | - | 1138
D | 2400 | REF04 | C040-02 | 127
D | 2400 | REF04 | C040-02 | 127
D | 2400 | REF04 | C040-02 | 127
D | 2420A | REF04 | C040-02 | 127
D | 2420B | REF04 | C040-02 | 127
D | 2420D | REF04 | C040-02 | 127
D | 2430 | SVD01 | - | 1138
 
Other Payer Secondary Identifier
Additional identifier for the other payer organization
837 - Health Care Claim Dental
D | 2330B | REF02 | - | 127
 
Other Payer Service Location Secondary Identifier
The non-destination payer's service location secondary identifier.
837 - Health Care Claim Dental
D | 2330F | REF02 | - | 127
 
Other Payer State or Province Code
The state or province code of the other payer's mailing address.
837 - Health Care Claim Dental
D | 2330B | N402 | - | 156
 
Other Payer Voided Claim Indicator
Indicates the claim has been voided.
837 - Health Care Claim Dental
D | 2320 | OI10 | - | 1073
 
Other Payer's Claim Control Number
A number assigned by the other payer to identify a claim. The number is usually referred to as an Internal Control Number (ICN), Claim Control Number (CCN) or a Document Control Number (DCN).
837 - Health Care Claim Dental
D | 2330B | REF02 | - | 127
 
Other Subscriber Address Line
Address line of the Other Subscriber's mailing address.
837 - Health Care Claim Dental
D | 2330A | N301 | - | 166
D | 2330A | N302 | - | 166
 
Other Subscriber City Name
The city name of the Other Subscriber.
837 - Health Care Claim Dental
D | 2330A | N401 | - | 19
 
Other Subscriber Country Code
The country code of the Other Subscriber's mailing address.
837 - Health Care Claim Dental
D | 2330A | N404 | - | 26
 
Other Subscriber Country Subdivision Code
The country subdivision code of the Other Subscriber's mailing address.
837 - Health Care Claim Dental
D | 2330A | N407 | - | 1715
 
Other Subscriber First Name
The first name of the Other Subscriber.
837 - Health Care Claim Dental
D | 2330A | NM104 | - | 1036
 
Other Subscriber Identifier
An identification number, assigned by the third party payer, to identify the Other Subscriber.
837 - Health Care Claim Dental
D | 2330A | NM109 | - | 67
 
Other Subscriber Last Name or Organization Name
The last name or organization name of the Other Subscriber.
837 - Health Care Claim Dental
D | 2330A | NM103 | - | 1035
 
Other Subscriber Middle Name or Initial
This is the middle name or initial of the Other Subscriber.
837 - Health Care Claim Dental
D | 2330A | NM105 | - | 1037
 
Other Subscriber Name Suffix
The suffix to the name of the Other Subscriber.
837 - Health Care Claim Dental
D | 2330A | NM107 | - | 1039
 
Other Subscriber Postal Zone or ZIP Code
The Postal ZIP code of the Other Subscriber's mailing address.
837 - Health Care Claim Dental
D | 2330A | N403 | - | 116
 
Other Subscriber Social Security Number
Identifier assigned to the other subscriber by the Social Security Administration.
837 - Health Care Claim Dental
D | 2330A | REF02 | - | 127
 
Other Subscriber State or Province Code
The state code of the Other Subscriber's mailing address.
837 - Health Care Claim Dental
D | 2330A | N402 | - | 156
 
Paid Service Unit Count
Units of service paid by the payer for coordination of benefits.
837 - Health Care Claim Dental
D | 2430 | SVD05 | - | 380
 
Patient Address Line
Address line of the street mailing address of the patient.
837 - Health Care Claim Dental
D | 2010CA | N301 | - | 166
D | 2010CA | N302 | - | 166
 
Patient Amount Paid
The amount the provider has received from the patient (or insured) toward payment of this claim.
837 - Health Care Claim Dental
D | 2300 | AMT02 | - | 782
 
Patient Birth Date
Date of birth of the patient.
837 - Health Care Claim Dental
D | 2010CA | DMG02 | - | 1251
 
Patient City Name
The city name of the patient.
837 - Health Care Claim Dental
D | 2010CA | N401 | - | 19
 
Patient Country Code
The country code of the patient.
837 - Health Care Claim Dental
D | 2010CA | N404 | - | 26
 
Patient Country Subdivision Code
The country subdivision code of the patient.
837 - Health Care Claim Dental
D | 2010CA | N407 | - | 1715
 
Patient First Name
The first name of the individual to whom the services were provided.
837 - Health Care Claim Dental
D | 2010CA | NM104 | - | 1036
 
Patient Gender Code
A code indicating the sex of the patient.
837 - Health Care Claim Dental
D | 2010CA | DMG03 | - | 1068
 
Patient Last Name
The last name of the individual to whom the services were provided.
837 - Health Care Claim Dental
D | 2010CA | NM103 | - | 1035
 
Patient Middle Name or Initial
The middle name or initial of the individual to whom the services were provided.
837 - Health Care Claim Dental
D | 2010CA | NM105 | - | 1037
 
Patient Name Suffix
Suffix to the name of the individual to whom the services were provided.
837 - Health Care Claim Dental
D | 2010CA | NM107 | - | 1039
 
Patient Postal Zone or ZIP Code
The ZIP Code of the patient.
837 - Health Care Claim Dental
D | 2010CA | N403 | - | 116
 
Patient State or Province Code
The State Postal Code of the patient.
837 - Health Care Claim Dental
D | 2010CA | N402 | - | 156
 
Pay-To Address Line
Address line of the provider to receive payment.
837 - Health Care Claim Dental
D | 2010AB | N301 | - | 166
D | 2010AB | N302 | - | 166
 
Pay-To Address State or Province Code
State or sub-country code of the entity to receive payment.
837 - Health Care Claim Dental
D | 2010AB | N402 | - | 156
 
Pay-To Plan Address Line
Street address of the Pay-To Plan.
837 - Health Care Claim Dental
D | 2010AC | N301 | - | 166
D | 2010AC | N302 | - | 166
 
Pay-To Plan City Name
City name of the Pay-To Plan.
837 - Health Care Claim Dental
D | 2010AC | N401 | - | 19
 
Pay-To Plan Organizational Name
Organization name of the health plan that is seeking reimbursement (Pay-To Plan).
837 - Health Care Claim Dental
D | 2010AC | NM103 | - | 1035
 
Pay-To Plan Postal Zone or ZIP Code
Postal zone or ZIP code of the Pay-To Plan.
837 - Health Care Claim Dental
D | 2010AC | N403 | - | 116
 
Pay-To Plan Primary Identifier
Identification number for the Pay-To Plan.
837 - Health Care Claim Dental
D | 2010AC | NM109 | - | 67
 
Pay-To Plan State or Province Code
State or province code of the Pay-to Plan.
837 - Health Care Claim Dental
D | 2010AC | N402 | - | 156
 
Pay-To Plan Tax Identification Number
Tax identification number of the plan to whom payment should be made.
837 - Health Care Claim Dental
D | 2010AC | REF02 | - | 127
 
Pay-to Address City Name
City name of the entity to receive payment.
837 - Health Care Claim Dental
D | 2010AB | N401 | - | 19
 
Pay-to Address Country Code
Country code of the entity to receive payment (for example, ZIP code).
837 - Health Care Claim Dental
D | 2010AB | N404 | - | 26
 
Pay-to Address Country Subdivision Code
Country subdivision code of the entity to receive payment (for example, ZIP code).
837 - Health Care Claim Dental
D | 2010AB | N407 | - | 1715
 
Pay-to Address Postal Zone or ZIP Code
Postal code of the entity to receive payment (for example, ZIP code).
837 - Health Care Claim Dental
D | 2010AB | N403 | - | 116
 
Pay-to Factoring Agent Address Line
The address line of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | N301 | - | 166
D | 2010AD | N302 | - | 166
 
Pay-to Factoring Agent City Name
The city of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | N401 | - | 19
 
Pay-to Factoring Agent Contact Name
The contact name for the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | PER02 | - | 93
 
Pay-to Factoring Agent Country Code
The country code of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | N404 | - | 26
 
Pay-to Factoring Agent Country Subdivision Code
The country subdivision code of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | N407 | - | 1715
 
Pay-to Factoring Agent First Name
The first name of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | NM104 | - | 1036
 
Pay-to Factoring Agent Last or Organization Name
The last name or organization name of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | NM103 | - | 1035
 
Pay-to Factoring Agent Middle Name or Initial
The middle name or initial of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | NM105 | - | 1037
 
Pay-to Factoring Agent Name Suffix
The name suffix of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | NM107 | - | 1039
 
Pay-to Factoring Agent Postal Zone or ZIP Code
The Postal Zone or ZIP code of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | N403 | - | 116
 
Pay-to Factoring Agent Primary Identifier
The primary identifier for the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | NM109 | - | 67
 
Pay-to Factoring Agent Secondary Identifier
The secondary identifier for the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | REF02 | - | 127
 
Pay-to Factoring Agent State or Province Code
The State or Province code of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | N402 | - | 156
 
Pay-to Factoring Agent Tax Identification Number
The tax identification number of the entity who purchased the financial obligation.
837 - Health Care Claim Dental
D | 2010AD | REF02 | - | 127
 
Pay-to Plan Country Code
Country code of the Pay-To Plan.
837 - Health Care Claim Dental
D | 2010AC | N404 | - | 26
 
Pay-to Plan Country Subdivision Code
Country subdivision code of the Pay-To Plan.
837 - Health Care Claim Dental
D | 2010AC | N407 | - | 1715
 
Pay-to Plan Secondary Identifier
Additional identifier for the Pay-To Plan.
837 - Health Care Claim Dental
D | 2010AC | REF02 | - | 127
 
Payer Address Line
Address line of the Payer's claim mailing address for this particular payer organization identification and claim office.
837 - Health Care Claim Dental
D | 2010BB | N301 | - | 166
D | 2010BB | N302 | - | 166
 
Payer City Name
The City Name of the Payer's claim mailing address for this particular payer ID and claim office.
837 - Health Care Claim Dental
D | 2010BB | N401 | - | 19
 
Payer Claim Control Number
A number assigned by the payer to identify a claim. The number is usually referred to as an Internal Control Number (ICN), Claim Control Number (CCN) or a Document Control Number (DCN).
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
 
Payer Country
The country code for the payer when the payer's country is not the United States of America.
837 - Health Care Claim Dental
D | 2010BB | N404 | - | 26
 
Payer Country Subdivision
The state, province or other subdivision identification of the payer's address when the payer's country is not the United States of America, including its territories, or Canada.
837 - Health Care Claim Dental
D | 2010BB | N407 | - | 1715
 
Payer Identifier
Number identifying the payer organization.
837 - Health Care Claim Dental
D | 2010BB | NM109 | - | 67
 
Payer Name
Name identifying the payer organization.
837 - Health Care Claim Dental
D | 2010BB | NM103 | - | 1035
 
Payer Paid Amount
The amount paid by the payer on this claim.
837 - Health Care Claim Dental
D | 2320 | AMT02 | - | 782
 
Payer Postal Zone or ZIP Code
The ZIP Code of the Payer's claim mailing address for this particular payer organization identification and claim office.
837 - Health Care Claim Dental
D | 2010BB | N403 | - | 116
 
Payer Responsibility Sequence Code
Code indicating the order in which benefits for this payer will be adjudicated when multiple payers are involved.
837 - Health Care Claim Dental
D | 2000B | SBR01 | - | 1138
 
Payer Secondary Identifier
Additional identifier for the payer.
837 - Health Care Claim Dental
D | 2010BB | REF02 | - | 127
 
Payer State or Province Code
State Postal Code of the Payer's claim mailing address for this particular payer organization identification and claim office.
837 - Health Care Claim Dental
D | 2010BB | N402 | - | 156
 
Payment Effective Date
The effective date of the payment.
837 - Health Care Claim Dental
D | 2330B | DTP03 | - | 1251
D | 2430 | DTP03 | - | 1251
 
Place of Service Code
The code that identifies where the service was performed.
837 - Health Care Claim Dental
D | 2300 | CLM05 | C023-01 | 1331
D | 2400 | SV303 | - | 1331
 
Policy Compliance Code
The code that specifies policy compliance.
837 - Health Care Claim Dental
D | 2300 | HCP14 | - | 1526
D | 2400 | HCP14 | - | 1526
 
Predetermination of Benefits Code
Code indicating that the associated claim is a predetermination of benefits request rather than a claim or encounter.
837 - Health Care Claim Dental
D | 2300 | CLM19 | - | 1383
 
Predetermination of Benefits Identifier
Identifier assigned to a Predetermination of Benefits.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
D | 2400 | REF02 | - | 127
 
Pricing Methodology
Pricing methodology at which the claim or line item has been priced or repriced.
837 - Health Care Claim Dental
D | 2300 | HCP01 | - | 1473
D | 2400 | HCP01 | - | 1473
 
Prior Authorization Number
A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
D | 2400 | REF02 | - | 127
 
Prior Placement Date
The date of Prior Placement of the Prosthesis, Crown or Inlay, if any reason for service is replacement.
837 - Health Care Claim Dental
D | 2400 | DTP03 | - | 1251
 
Procedure Code
Code identifying the procedure, product or service.
837 - Health Care Claim Dental
D | 2400 | SV301 | C003-02 | 234
D | 2430 | SVD03 | C003-02 | 234
 
Procedure Code Description
Description clarifying the Product/Service Procedure Code and related data elements.
837 - Health Care Claim Dental
D | 2400 | SV301 | C003-07 | 352
 
Procedure Count
Number of Procedures
837 - Health Care Claim Dental
D | 2400 | SV306 | - | 380
 
Procedure Modifier
This identifies special circumstances related to the performance of the service.
837 - Health Care Claim Dental
D | 2400 | SV301 | C003-03 | 1339
D | 2400 | SV301 | C003-04 | 1339
D | 2400 | SV301 | C003-05 | 1339
D | 2400 | SV301 | C003-06 | 1339
D | 2430 | SVD03 | C003-03 | 1339
D | 2430 | SVD03 | C003-04 | 1339
D | 2430 | SVD03 | C003-05 | 1339
D | 2430 | SVD03 | C003-06 | 1339
 
Product or Service ID Qualifier
Code identifying the type/source of the descriptive number used in Product/Service ID (234).
837 - Health Care Claim Dental
D | 2400 | SV301 | C003-01 | 235
D | 2400 | HCP09 | - | 235
D | 2400 | HCP09 | - | 235
D | 2430 | SVD03 | C003-01 | 235
 
Property & Casualty Claim Number
Identification number for property & casualty claim associated with the services identified on the bill.
837 - Health Care Claim Dental
D | 2010CA | REF02 | - | 127
 
Property & Casualty Patient Contact Name
Name of the person to whom inquiries about the claim should be directed.
837 - Health Care Claim Dental
D | 2010CA | PER02 | - | 93
 
Property & Casualty Patient Identifier
Identification number of the patient on a Property & Casualty claim.
837 - Health Care Claim Dental
D | 2010CA | REF02 | - | 127
 
Property Casualty Claim Number
Identification number for property casualty claim associated with the services identified on the bill.
837 - Health Care Claim Dental
D | 2010BA | REF02 | - | 127
 
Prosthesis, Crown, or Inlay Code
Code Specifying the Placement Status for the Dental Work.
837 - Health Care Claim Dental
D | 2400 | SV305 | - | 1358
 
Provider Agreement Code
Code indicating the type of agreement under which the provider is submitting this claim.
837 - Health Care Claim Dental
D | 2300 | CLM16 | - | 1360
D | 2320 | OI05 | - | 1360
 
Provider Code
Code identifying the type of provider.
837 - Health Care Claim Dental
D | 2000A | PRV01 | - | 1221
D | 2310B | PRV01 | - | 1221
D | 2310D | PRV01 | - | 1221
D | 2420A | PRV01 | - | 1221
D | 2420B | PRV01 | - | 1221
 
Provider Taxonomy Code
Code designating the provider type, classification, and specialization.
837 - Health Care Claim Dental
D | 2000A | PRV03 | - | 127
D | 2310B | PRV03 | - | 127
D | 2310D | PRV03 | - | 127
D | 2420A | PRV03 | - | 127
D | 2420B | PRV03 | - | 127
 
Provider or Supplier Signature Indicator
An indicater that the provider of service reported on this claim acknowledges the performance of the service and authorizes payment, and that a signature is on file in the provider's office.
837 - Health Care Claim Dental
D | 2300 | CLM06 | - | 1073
 
Provider's Assigned Claim Identifier
The identifier generated by the provider for the purposes of reassociation to their claim accounts receivable.
837 - Health Care Claim Dental
D | 2300 | CLM01 | - | 1028
 
Receiver Name
Name of organization receiving the transaction.
837 - Health Care Claim Dental
H | 1000B | NM103 | - | 1035
 
Receiver Primary Identifier
Primary identification number for the receiver of the transaction.
837 - Health Care Claim Dental
H | 1000B | NM109 | - | 67
 
Reference Identification Qualifier
Code qualifying the reference identification.
837 - Health Care Claim Dental
D | 2000A | PRV02 | - | 128
D | 2010AA | REF01 | - | 128
D | 2010AC | REF01 | - | 128
D | 2010AC | REF01 | - | 128
D | 2010AD | REF01 | - | 128
D | 2010AD | REF01 | - | 128
D | 2010BA | REF01 | - | 128
D | 2010BA | REF01 | - | 128
D | 2010BB | REF01 | - | 128
D | 2010BB | REF01 | - | 128
D | 2010CA | REF01 | - | 128
D | 2010CA | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2300 | REF01 | - | 128
D | 2310A | REF01 | - | 128
D | 2310B | PRV02 | - | 128
D | 2310B | REF01 | - | 128
D | 2310C | REF01 | - | 128
D | 2310D | PRV02 | - | 128
D | 2310D | REF01 | - | 128
D | 2330A | REF01 | - | 128
D | 2330B | REF01 | - | 128
D | 2330B | REF01 | - | 128
D | 2330B | REF01 | - | 128
D | 2330B | REF01 | - | 128
D | 2330B | REF01 | - | 128
D | 2330B | REF01 | - | 128
D | 2330C | REF01 | - | 128
D | 2330D | REF01 | - | 128
D | 2330E | REF01 | - | 128
D | 2330F | REF01 | - | 128
D | 2330G | REF01 | - | 128
D | 2400 | REF01 | - | 128
D | 2400 | REF04 | C040-01 | 128
D | 2400 | REF01 | - | 128
D | 2400 | REF04 | C040-01 | 128
D | 2400 | REF01 | - | 128
D | 2400 | REF01 | - | 128
D | 2400 | REF01 | - | 128
D | 2400 | REF01 | - | 128
D | 2400 | REF04 | C040-01 | 128
D | 2420A | PRV02 | - | 128
D | 2420A | REF01 | - | 128
D | 2420A | REF04 | C040-01 | 128
D | 2420B | PRV02 | - | 128
D | 2420B | REF01 | - | 128
D | 2420B | REF04 | C040-01 | 128
D | 2420D | REF01 | - | 128
D | 2420D | REF04 | C040-01 | 128
 
Referral Number
Referral authorization number.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
D | 2400 | REF02 | - | 127
 
Referring Provider First Name
The first name of provider who referred the patient to the provider of service on this claim.
837 - Health Care Claim Dental
D | 2310A | NM104 | - | 1036
 
Referring Provider Identifier
The identification number for the referring physician.
837 - Health Care Claim Dental
D | 2310A | NM109 | - | 67
 
Referring Provider Last Name
The Last Name of Provider who referred the patient to the provider of service on this claim.
837 - Health Care Claim Dental
D | 2310A | NM103 | - | 1035
 
Referring Provider Middle Name or Initial
Middle name or initial of the provider who is referring patient for care.
837 - Health Care Claim Dental
D | 2310A | NM105 | - | 1037
 
Referring Provider Name Suffix
Suffix to the name of the provider referring the patient for care.
837 - Health Care Claim Dental
D | 2310A | NM107 | - | 1039
 
Referring Provider Secondary Identifier
Additional identification number for the provider referring the patient for service.
837 - Health Care Claim Dental
D | 2310A | REF02 | - | 127
 
Reimbursement Rate
Rate used when payment is based upon a percentage of applicable charges.
837 - Health Care Claim Dental
D | 2320 | MOA01 | - | 954
 
Reject Reason Code
Code assigned by issuer to identify reason for rejection.
837 - Health Care Claim Dental
D | 2300 | HCP13 | - | 901
D | 2400 | HCP13 | - | 901
 
Related Causes Code
Code identifying an accompanying cause of an illness, injury, or an accident.
837 - Health Care Claim Dental
D | 2300 | CLM11 | C024-01 | 1362
D | 2300 | CLM11 | C024-02 | 1362
 
Release of Information Code
Code indicating whether the provider has on file a signed statement permitting the release of medical data to other organizations.
837 - Health Care Claim Dental
D | 2300 | CLM09 | - | 1363
D | 2320 | OI06 | - | 1363
 
Remaining Patient Liability
In the judgement of the provider, the amount that remained to be paid after adjudication by this Other Payer.
837 - Health Care Claim Dental
D | 2320 | AMT02 | - | 782
D | 2430 | AMT02 | - | 782
 
Remark Code
Code indicating a code from a specific industry code list, such as the Health Care Claim Status Code list.
837 - Health Care Claim Dental
D | 2320 | RAS03 | C058-03 | 1271
D | 2320 | RAS03 | C058-04 | 1271
D | 2320 | RAS03 | C058-05 | 1271
D | 2320 | RAS03 | C058-06 | 1271
D | 2320 | RAS03 | C058-07 | 1271
D | 2320 | LQ02 | - | 1271
D | 2430 | RAS03 | C058-03 | 1271
D | 2430 | RAS03 | C058-04 | 1271
D | 2430 | RAS03 | C058-05 | 1271
D | 2430 | RAS03 | C058-06 | 1271
D | 2430 | RAS03 | C058-07 | 1271
D | 2430 | LQ02 | - | 1271
 
Rendering Provider First Name
The first name of the provider who performed the service.
837 - Health Care Claim Dental
D | 2310B | NM104 | - | 1036
D | 2420A | NM104 | - | 1036
 
Rendering Provider Identifier
The identifier assigned by the Payer to the provider who performed the service.
837 - Health Care Claim Dental
D | 2310B | NM109 | - | 67
D | 2420A | NM109 | - | 67
 
Rendering Provider Last Name
The last name of the provider who performed the service.
837 - Health Care Claim Dental
D | 2310B | NM103 | - | 1035
D | 2420A | NM103 | - | 1035
 
Rendering Provider Middle Name or Initial
Middle name or initial of the provider who has provided the services to the patient.
837 - Health Care Claim Dental
D | 2310B | NM105 | - | 1037
D | 2420A | NM105 | - | 1037
 
Rendering Provider Name Suffix
Name suffix of the provider who has provided the services to the patient.
837 - Health Care Claim Dental
D | 2310B | NM107 | - | 1039
D | 2420A | NM107 | - | 1039
 
Rendering Provider Secondary Identifier
Additional identifier for the provider providing care to the patient.
837 - Health Care Claim Dental
D | 2310B | REF02 | - | 127
D | 2420A | REF02 | - | 127
 
Replacement Date
Replacement Date for appliance or prosthesis
837 - Health Care Claim Dental
D | 2400 | DTP03 | - | 1251
 
Repriced Allowed Amount
The maximum amount determined by the repricer as being allowable under the provisions of the contract prior to the determination of the actual payment.
837 - Health Care Claim Dental
D | 2300 | HCP02 | - | 782
D | 2400 | HCP02 | - | 782
 
Repriced Approved HCPCS Code
The HCPCS code that describes the services as approved by the repricer.
837 - Health Care Claim Dental
D | 2400 | HCP10 | - | 234
D | 2400 | HCP10 | - | 234
 
Repriced Approved Service Unit Count
Number of service units approved by pricing or repricing entity.
837 - Health Care Claim Dental
D | 2400 | HCP12 | - | 380
D | 2400 | HCP12 | - | 380
 
Repriced Claim Reference Number
Identification number, assigned by a repricing organization, to identify the claim.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
 
Repriced Line Item Reference Number
Identification number of a line item repriced by a third party or prior payer.
837 - Health Care Claim Dental
D | 2400 | REF02 | - | 127
 
Repriced Savings Amount
The amount of savings related to Third Party Organization claims.
837 - Health Care Claim Dental
D | 2300 | HCP03 | - | 782
D | 2400 | HCP03 | - | 782
 
Repricer Received Date
Date the claim was received by the repricer organization.
837 - Health Care Claim Dental
D | 2300 | DTP03 | - | 1251
 
Repricing Organization Identifier
Reference or identification number of the repricing organization.
837 - Health Care Claim Dental
D | 2300 | HCP04 | - | 127
D | 2400 | HCP04 | - | 127
 
Repricing Per Diem or Flat Rate Amount
Amount used to determine the flat rate or per diem price by the repricing organization.
837 - Health Care Claim Dental
D | 2300 | HCP05 | - | 118
D | 2400 | HCP05 | - | 118
 
Service Allowed Amount
The amount the payer deems payable for this service, prior to considering patient responsibility.
837 - Health Care Claim Dental
D | 2430 | AMT02 | - | 782
 
Service Date
Date of service, such as the start date of the service, the end date of the service, or the single day date of the service.
837 - Health Care Claim Dental
D | 2300 | DTP03 | - | 1251
D | 2400 | DTP03 | - | 1251
 
Service Line Paid Amount
Amount paid by the indicated payer for a service line
837 - Health Care Claim Dental
D | 2430 | SVD02 | - | 782
 
Service Location Address Line
Address line of the service location address.
837 - Health Care Claim Dental
D | 2310C | N301 | - | 166
D | 2310C | N302 | - | 166
D | 2420D | N301 | - | 166
D | 2420D | N302 | - | 166
 
Service Location City Name
City of the service location.
837 - Health Care Claim Dental
D | 2310C | N401 | - | 19
D | 2420D | N401 | - | 19
 
Service Location Country Code
Country code for the service location.
837 - Health Care Claim Dental
D | 2310C | N404 | - | 26
D | 2420D | N404 | - | 26
 
Service Location Country Subdivision Code
Country Subdivision code for the service location.
837 - Health Care Claim Dental
D | 2310C | N407 | - | 1715
D | 2420D | N407 | - | 1715
 
Service Location Name
Name of the service location.
837 - Health Care Claim Dental
D | 2310C | NM103 | - | 1035
D | 2420D | NM103 | - | 1035
 
Service Location Postal Zone or ZIP Code
Postal zone code or ZIP code for the service location.
837 - Health Care Claim Dental
D | 2310C | N403 | - | 116
D | 2420D | N403 | - | 116
 
Service Location Primary Identifier
The primary identification number for the service location.
837 - Health Care Claim Dental
D | 2420D | NM109 | - | 67
 
Service Location Secondary Identifier
Secondary identification number for the service location.
837 - Health Care Claim Dental
D | 2310C | REF02 | - | 127
D | 2420D | REF02 | - | 127
 
Service Location State or Province Code
State or province for the service location.
837 - Health Care Claim Dental
D | 2310C | N402 | - | 156
D | 2420D | N402 | - | 156
 
Special Program Indicator
A code indicating the Special Program under which the services rendered to the patient were performed.
837 - Health Care Claim Dental
D | 2300 | CLM12 | - | 1366
 
State Care Tax
Tax reported for State purposes (not Sales Tax).
837 - Health Care Claim Dental
D | 2400 | AMT02 | - | 782
 
State of Claim Jurisdiction
Jurisdictional state that defines the rules, regulations, statutes, or guidelines under which the electronic claim/bill is being submitted.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127
 
Submitter Contact Name
Name of the person at the submitter organization to whom inquiries about the transaction should be directed.
837 - Health Care Claim Dental
H | 1000A | PER02 | - | 93
 
Submitter First Name
The first name of the person submitting the transaction or receiving the transaction, as identified by the preceding identification code.
837 - Health Care Claim Dental
H | 1000A | NM104 | - | 1036
 
Submitter Identifier
Code or number identifying the entity submitting the claim.
837 - Health Care Claim Dental
H | 1000A | NM109 | - | 67
 
Submitter Last or Organization Name
The last name or the organizational name of the entity submitting the transaction
837 - Health Care Claim Dental
H | 1000A | NM103 | - | 1035
 
Submitter Middle Name or Initial
The middle name or initial of the person submitting the transaction.
837 - Health Care Claim Dental
H | 1000A | NM105 | - | 1037
 
Subscriber Address Line
Address line of the current mailing address of the insured individual or subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | N301 | - | 166
D | 2010BA | N302 | - | 166
 
Subscriber Birth Date
The date of birth of the subscriber to the indicated coverage or policy.
837 - Health Care Claim Dental
D | 2010BA | DMG02 | - | 1251
 
Subscriber City Name
The City Name of the insured individual or subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | N401 | - | 19
 
Subscriber Country Code
The code identifying the country of the insured or subscriber address.
837 - Health Care Claim Dental
D | 2010BA | N404 | - | 26
 
Subscriber Country Subdivision Code
The country subdivision code of the insured or subscriber address.
837 - Health Care Claim Dental
D | 2010BA | N407 | - | 1715
 
Subscriber First Name
The first name of the insured individual or subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | NM104 | - | 1036
 
Subscriber Gender Code
Code indicating the sex of the subscriber to the indicated coverage or policy.
837 - Health Care Claim Dental
D | 2010BA | DMG03 | - | 1068
 
Subscriber Group Name
Name of the group through which the coverage is provided to the subscriber.
837 - Health Care Claim Dental
D | 2000B | SBR04 | - | 93
 
Subscriber Group or Policy Number
The identifier assigned by the health plan or administrator to identify the group through which the coverage is provided to the subscriber.
837 - Health Care Claim Dental
D | 2000B | SBR03 | - | 127
 
Subscriber Last Name or Organization Name
The last name or organization name of the subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | NM103 | - | 1035
 
Subscriber Middle Name or Initial
The middle name or initial of the subscriber to the indicated coverage or policy.
837 - Health Care Claim Dental
D | 2010BA | NM105 | - | 1037
 
Subscriber Name Suffix
Suffix of the insured individual or subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | NM107 | - | 1039
 
Subscriber Postal Zone or ZIP Code
The ZIP Code of the insured individual or subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | N403 | - | 116
 
Subscriber Primary Identifier
Primary identification number of the subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | NM109 | - | 67
 
Subscriber Social Security Number
This is the number assigned to the subscriber by the Social Security Administration.
837 - Health Care Claim Dental
D | 2010BA | REF02 | - | 127
 
Subscriber State or Province Code
The State Postal Code of the insured individual or subscriber to the coverage.
837 - Health Care Claim Dental
D | 2010BA | N402 | - | 156
 
Supervising Provider First Name
The First Name of the Provider who supervised the rendering of a service on this claim.
837 - Health Care Claim Dental
D | 2310E | NM104 | - | 1036
D | 2420C | NM104 | - | 1036
 
Supervising Provider Identifier
The Identification Number for the Supervising Provider.
837 - Health Care Claim Dental
D | 2310E | NM109 | - | 67
D | 2420C | NM109 | - | 67
 
Supervising Provider Last Name
The Last Name of the Provider who supervised the rendering of a service on this claim.
837 - Health Care Claim Dental
D | 2310E | NM103 | - | 1035
D | 2420C | NM103 | - | 1035
 
Supervising Provider Middle Name or Initial
Middle name or initial of the provider supervising care rendered to the patient.
837 - Health Care Claim Dental
D | 2310E | NM105 | - | 1037
D | 2420C | NM105 | - | 1037
 
Supervising Provider Name Suffix
Suffix to the name of the provider supervising care rendered to the patient.
837 - Health Care Claim Dental
D | 2310E | NM107 | - | 1039
D | 2420C | NM107 | - | 1039
 
Temporary Solution for a Statutory/Regulatory Requirement
The unexpected data requirement of a legislative authority.
837 - Health Care Claim Dental
D | 2300 | K301 | - | 449
D | 2400 | K301 | - | 449
 
Terms Discount Percentage
Discount percentage available to the payer for payment within a specific time period.
837 - Health Care Claim Dental
D | 2300 | CN105 | - | 338
D | 2400 | CN105 | - | 338
 
Tooth Code
An indication of the tooth on which services were performed or will be performed.
837 - Health Care Claim Dental
D | 2400 | TOO02 | - | 1271
 
Tooth Number
Standard identification number of a tooth.
837 - Health Care Claim Dental
D | 2300 | DN201 | - | 127
 
Tooth Status Code
Code specifying the status of a tooth
837 - Health Care Claim Dental
D | 2300 | DN202 | - | 1368
 
Tooth Surface Code
The surface(s) of the tooth on which services were performed or will be performed.
837 - Health Care Claim Dental
D | 2400 | TOO03 | C005-01 | 1369
D | 2400 | TOO03 | C005-02 | 1369
D | 2400 | TOO03 | C005-03 | 1369
D | 2400 | TOO03 | C005-04 | 1369
D | 2400 | TOO03 | C005-05 | 1369
 
Total Claim Charge Amount
The sum of all charges included within this claim.
837 - Health Care Claim Dental
D | 2300 | CLM02 | - | 782
 
Transaction Segment Count
A tally of all segments between the ST and the SE segments including the ST and SE segments.
837 - Health Care Claim Dental
D | | SE01 | - | 96
 
Transaction Set Control Number
The unique identification number within a transaction set.
837 - Health Care Claim Dental
H | | ST02 | - | 329
D | | SE02 | - | 329
 
Transaction Set Creation Date
Identifies the date the submitter created the transaction.
837 - Health Care Claim Dental
H | | BHT04 | - | 373
 
Transaction Set Creation Time
Time file is created for transmission.
837 - Health Care Claim Dental
H | | BHT05 | - | 337
 
Transaction Set Identifier Code
Code uniquely identifying a Transaction Set.
837 - Health Care Claim Dental
H | | ST01 | - | 143
 
Transaction Set Purpose Code
Code identifying purpose of transaction set.
837 - Health Care Claim Dental
H | | BHT02 | - | 353
 
Unit or Basis for Measurement Code
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken.
837 - Health Care Claim Dental
D | 2400 | HCP11 | - | 355
D | 2400 | HCP11 | - | 355
 
Value Added Network Trace Number
Unique Identification number for a transaction assigned by a Value Added Network, Clearinghouse, or other transmission entity.
837 - Health Care Claim Dental
D | 2300 | REF02 | - | 127