EDI 837 Dental. Version 005010X224A2
Example: Orthodontic treatment plan
ISA*00* *00* *ZZ*123456789012345*ZZ*123456789012346*080503*1705*>*00501*000010216*0*T*:
GS*HC*1234567890*1234567890*20080503*1705*20213*X*005010X224A2
ST*837*0322*005010X224A2
BHT*0019*00*0123*20061123*1023*CH
NM1*41*2*JOHN DOE*****46*940001
PER*IC*SALLY*TE*7175555555
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666
HL*1**20*1
PRV*BI*PXC*1223G0001X
NM1*85*1*JOHN*DOE****XX*2345678901
N3*123 TOOTH DRIVE
N4*MIAMI*FL*33411
REF*EI*587654321
HL*2*1*22*0
SBR*P*18*******CI
NM1*IL*1*SMITH*JANE****MI*111223333
N3*236 N MAIN ST
N4*MIAMI*FL*33413
DMG*D8*19911029*M
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666
CLM*SMITH788*4000***11:B:1*Y*A*Y*I
DTP*452*D8*20061115
DN1*36
LX*1
SV3*AD:D8080*4000****1
SE*24*0322
GE*1*20213
IEA*1*000010216
JSON used to create the above EDI Message
{
"doValidation": "Yes",
"assignDefaultValues": "Yes",
"interChangeHeader": {
"authorizationQualifier": "00",
"securityQualifier": "00",
"interChangeIDQualifierSender": "ZZ",
"interChangeIDQualifierReceiver": "ZZ",
"submitterID": "123456789012345",
"receiverID": "123456789012346",
"interChangeDate": "080503",
"interChangeTime": "1705",
"ediControlNumber": "000010216",
"repetitionSeparator": "\u003e",
"acknowledgementRequested": "0",
"usageIndicator": "T",
"componentElementSeparator": ":",
"controlVersionNumber": "00501"
},
"groupHeader": {
"groupTransactionDate": "20080503",
"applicationSenderCode": "1234567890",
"applicationReceiverCode": "1234567890",
"groupTransactionTime": "1705",
"groupControlNumber": "20213",
"ediVersion": "005010X224A2",
"functionalIdentifierCode": "HC",
"responsibleAgencyCode": "X"
},
"transactionSets": [
{
"ediTransactionSet": "837",
"transactionControlNumber": "0322",
"originatorAppTransNumber": "0123",
"transactionDate": "20061123",
"transactionTime": "1023",
"transactionPurposeCode": "00",
"transactionTypeCode": "CH",
"implementationVersion": "005010X224A2",
"hierarchicalStructureCode": "0019",
"receiver": {
"etinNumber": "999996666",
"entityType": "2",
"lastName": "KEY INSURANCE COMPANY",
"identifierCode": "46",
"identifierValue": "999996666",
"entityIdentifierCode": "40"
},
"submitter": {
"etinNumber": "940001",
"contactName": "SALLY",
"contactPhone": "7175555555",
"entityType": "2",
"lastName": "JOHN DOE",
"identifierCode": "46",
"identifierValue": "940001",
"entityIdentifierCode": "41"
},
"claimsList": [
{
"claimIndex": 1,
"claimNo": "SMITH788",
"billedAmount": "4000",
"pos": "11",
"claimType": "1",
"providerSignIndicator": "Y",
"providerAcceptAssCode": "A",
"benefitAssIndicator": "Y",
"releaseInfoCode": "I",
"billingProviderDTO": {
"entityType": "1",
"lastName": "JOHN",
"firstName": "DOE",
"npi": "2345678901",
"address1": "123 TOOTH DRIVE",
"city": "MIAMI",
"state": "FL",
"taxonomyCode": "1223G0001X",
"zip": "33411",
"taxNo": "587654321"
},
"payerDTO": {
"entityIdentifierCode": "PR",
"name": "KEY INSURANCE COMPANY",
"payerID": "999996666"
},
"subscriberDTO": {
"entityType": "1",
"lastName": "SMITH",
"firstName": "JANE",
"address1": "236 N MAIN ST",
"city": "MIAMI",
"state": "FL",
"zip": "33413",
"dob": "19911029",
"gender": "M",
"payerRespon": "P",
"claimFillingIndicator": "CI",
"policyNo": "111223333",
"insuredRelation": "18"
},
"appliancePlacementDate": "20061115",
"orthoDonticTotalMonths": "36",
"lineItems": [
{
"claimIndex": 1,
"claimNo": "SMITH788",
"lineItemIndex": 1,
"procedureCode": "D8080",
"procedureType": "AD",
"billedAmount": "4000",
"chargesPerUnit": "4000",
"units": "1",
"lineItemId": ""
}
],
"claimICDs": " "
}
]
}
]
}
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