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837 Dental Section - PM

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Set the default 837 Dental billing file values.

Note: Certain fields on this form depend on the version of 837 Dental Billing you are using. These fields will be noted and designated with the corresponding version number.

Prerequisites:

  • This section is enabled through the Enable Dental Billing registry setting.

  • A Guarantor and Program must be chosen in order to access this section.

  1. In the Submitter Name (1000A-NM1-03) field, enter the name to populate the 1000A-NM1-03 segment.
  2. In the Submitter Contact Name (1000A-PER-02) field, enter the contact name, which will populate the 1000A-PER-02 segment.
  3. In the Submitter Telephone Number (1000A-PER-04) field, enter the phone number to populate the 1000A-PER-04 segment.
  4. In the Submitter Primary Identification # (1000A-NM1-09) field, enter the primary identification number to populate the 1000A-NM1-09 segment.
  5. In the Receiver Name (1000B-NM1-03) field, enter the name to populate the 1000B-NM1-03 segment.
  6. In the Receiver Primary Identification # (1000B-NM1-09) field, enter the receiver primary identification number to populate the 1000B-NM1-09 segment.
  7. In the Provider Code (2000A-PRV-01) field, select the provider code.
  8. In the Reference Identification (2000A-PRV-03) field, enter the provider identification.
  9. In the Billing Provider Name (2010AA-NM1-03) field, type the agency name.
  10. In the Billing Provider Primary Identification Code Qualifier (2010AA-NM1-08) field, select the value from the list. This value populates the 2010AA-NM1-08 segment.
  11. In the Billing Provider Primary Identification # (2010AA-NM1-09) field, type the agency Primary Identification number.
  12. In the Billing Provider Address 1 (2010AA-N3-01) field, type the agency street location information .
  13. In the Billing Provider Address 2 (2010AA-N3-02) — If applicable, type additional address information .
  14. In the Billing Provider ZIP Code (2010AA-N4-03) field, type the agency ZIP Code information.
  15. In the Billing Provider City (2010AA-N4-01) field, type the agency city information.
  16. In the Billing Provider State (2010AA-N4-01) field, select the state from the list.
  17. In the Billing Provider Tax Identification Code Qualifier field, select the type for the billing provider tax ID number (version 5010 only).
  18. In the Billing Provider Tax Identification Number field, enter the tax ID number (version 5010 only).
  19. In the Billing Provider UPIN/License Information Code Qualifier field, select the type for the UPIN/License code (version 5010 only).
  20. In the Billing Provider UPIN/License Information field, enter the UPIN/license code (version 5010 only).
  21. In the Billing Provider Secondary Identification Code Qualifier field, select the value from the list. The value selected populates the 2010AA-REF-01 segment.
  22. In the Billing Provider Secondary Identification field, type the agency Secondary Identification number. This value populates the 2010AA-REF-02 segment.
  23. In the Billing Provider Contact Name (2010AA-PER-02) field, type the name of the contact person. This value populates the 2010AA-PER-02 segment.
  24. In the Billing Provider Phone # (2010AA-PER-04) field, type the contact phone number. This value populates the 2010AA-PER-04 segment.
  25. In the Payer Identification Code Qualifier (2010BB/2330B-NM1-08) field, select the value that populates the 2010BB/2330B-NM1-08 segments. This list is edited and maintained under Other Tabled Files (field: 12032) of the Dictionary Update form.
  26. In the Payer Identification # (2010BB/2330B-NM1-09) field, type the agency Primary Identification number. This value populates the 2010BB/ 2330B-NM1-09 segments.
  27. In the Claim Note Reference Code (837D-2300-NTE-01) field, select the value from the list. The selected value populates the 2300-NTE-01 segment.
  28. In the Claim Note Text (837D-2300-NTE-02) field, type the claim note text. This value populates the 2300-NTE-02 segment.
  29. In the Facility Identification Code Qualifier (2310C-NM1-08) field, select the value that populates the 2310C-NM1-08 segment.
  30. In the Facility Identification Code (2310C-NM1-09) field, type the agency Facility Identification number. This value populates the 2310C-NM1-09 segment.
  31. In the Facility Reference Identification Qualifier (2310C-REF-01) fields, select the values that populate the corresponding iterations of the 2310C-REF-01 segment.
  32. In the Facility Reference Identification (2310C-REF-02) fields, type the agency Facility Reference Identification for the corresponding iterations to include in the 2310C-REF-02 segment.
  33. In the Amount To Display (2320-AMT:Payer Paid Amount-02) field, select Zero to allow the display of zeroes in the amount; select Payer Paid Amount to display the amount paid by the payer. Select Total Claim Charge Amount (2300-CLM-02) to display the total claim charge.
  34. In the Suppress Payer Paid Amount (2320-AMT) field:

    • Select No to exclude zero dollar services.

    • Select When Amount Is Zero to exclude services when the amount is zero.

    • Select When Total Liability for Other Payers Is Zero to exclude services when the total liability for the other payers is zero.

  35. In the Service Note Reference Code (837D-2400-NTE-01) field, select the value for the service code.
  36. In the Service Note Text (837D-2400-NTE-02) field, type the service note text. This value populates the 837D-2400-NTE-02 segment.
  37. In the Include Service Level Adjudication Information (2430) field, select Yes to include service level adjudication information in loop 2430; select No to bypass this functionality.
  38. In the Authorization Information Qualifier (ISA-01) field, select the value that populates the ISA-01 segment.
  39. In the Authorization Information (ISA-02) field, enter the authorization information. This value populates the ISA-02 segment. This field requires 10 digits.
  40. In the Security Information Qualifier (ISA-03) field, select the value that populates the ISA-03 segment.
  41. In the Security Information (ISA-04) field, type the 10 digit security information.
  42. In the Interchange Sender ID Qualifier (ISA-05) field, select the value that populates the ISA-05 segment.
  43. In the Interchange Sender ID (ISA-06) field, type the 15-digit ID information.
  44. In the Interchange Receiver ID Qualifier (ISA-07) field, select the ID type for the Interchange receiver ID.
  45. In the Interchange Receiver ID (ISA-08) field, type the 15-digit ID information.
  46. In the Repetition Separator (ISA-11) field, enter a character to be used as the repetition separator (version 5010 only).

    • The pipe/vertical bar character [ | ] is not permitted as a value in this field. To enable the vertical bar as the separator character, enter another character and then select Vertical Bar in the Repetition Separator Override field.

  47. In the Acknowledgement Requested (ISA-14) field, select the value that populates the ISA-14 segment.
  48. In the Usage Indicator (ISA-15) field, select the value that populates the ISA-15 segment.
  49. In the Application Sender's Code (GS-02) field, type the information. This value populates the GS-02 segment. This field requires between 2 and 15 digits.
  50. In the Application Receiver's Code (GS-03) field, type the information. This value populates the GS-03 segment. This field requires between 2 and 15 digits.
  51. In the Include Zero Dollar Services field, select Yes to include zero dollar services; select No to exclude zero dollar services.
  52. In the If the Loop/Segment Information At The Service Level... field, choose Yes to exclude the Loop/Segment information at the service level; choose No to include the Loop/Segment information at the service level.
  53. In the If The Begin/From Date Is The Same As The End/To Date... field, select Yes to use the D8 format when the begin and end dates are the same; select No to use the RD8 format instead.
  54. In the Suppress Claim Level Adjustments/Service Level Adjustments When Total is Zero field, select whether or not to remove from 2320-CAS/2430-CAS any claim adjustment group/reason code pairs that have a total of zero.
  55. In the Select Segments To Suppress field, select the loops/segments to suppress.
► Dictionary Values
  • Provider Code (2000A-PRV-01)
  • Billing Provider Primary Identification Code Qualifier (2010AA-NM1-08)
  • Billing Provider Secondary Identification Code Qualifier
  • Claim Note Reference Code (837D-2300-NTE-01)
  • Facility Identification Code Qualifier (2310C-NM1-08)
  • Facility Reference Identification Qualifier (2310C-REF-01)
  • Service Note Reference Code (837D-2400-NTE-01)
  • Authorization Information Qualifier (ISA-01)
  • Security Information Qualifier (ISA-03)
  • Interchange Sender ID Qualifier (ISA-05)
  • Interchange Receiver ID Qualifier (ISA-07)
  • Acknowledgement Requested (ISA-14)
  • Usage Indicator (ISA-15)
► Registry Settings
  • Enable Dental Billing
  • Enable Replacement Date (2400-DTP)
  • Enable Subscriber Policy Number Override
  • Include Patient Remaining Liability
  • Include Payer Secondary Id
  • Include Secondary Submitter EDI Contact Information (1000A-PER)
  • Patient Amount Paid (2300-AMT)
  • Rendering Provider Name (Loop 2310B)
  • Sort 'Claim Information' By Treatment String Values
  • Specify A Prefix Value For Patient Account Number
  • Specify Functional Group Time Format
  • Specify Loops/Segments To Suppress
  • Specify Rendering/Attending Provider At Guarantor/Program Level

 

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