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5010 Dental Claim Billing Standard – J430 v3.2

 

UHIN Dental Claim Billing Standard                                                                        

 

Approved

 

UHIN STANDARDS COMMITTEE

Version 3.2

5010 Dental Claim Billing Standard – J430

 

 

Purpose: The purpose of the Dental Billing Standard, is to clearly describe the standard use of each Item Number (for print images) and its crosswalk to the HIPAA 837 005010X0224A1 Dental implementation guide.  UHIN Dental Billing Standard is compatible with all HIPAA requirements.

 

Applicability: This Standard applies to all dental claims, pre-determinations, and encounters.

 

Basic Concepts: Item Number use is derived from the ADA 2012 Dental claim form instructions.  A crosswalk from the Item Numbers to the ASC X12 837 005010X224A1 Implementation Guide is listed showing loop and segment/element (e.g., 2010AA NM104 means Loop 2010AA, segment NM1, element 04). This standard adopts the ADA Dental Claim Form J430 as the only official Paper Dental Claim for paper claims.

 

Detail:

  1. Explanations on the use of each ADA Item Number (Box Number) are given below. Dental Claim Form completion instructions may be found at:

http://www.ada.org/sections/professionalResources/pdfs/ada_dental_claim_form_completion_instructions_2012.pdf  

  1. Explanations regarding the use of the ASC X12 data elements are given in the ASC X12 837 005010X224A1 implementation guide.
  2. If an Item Number is marked “Not cross walked” this means that this data element is not carried in the X12 Electronic Format.
  3. Any data elements required by X12 that do not have a designated Item Number are placed outside the structured form and are considered “Out of Form”.  Commonly placed in the top Right Hand Corner of the Claim Form. Rationale for including additional data elements that are not found on the paper form: If an element is always or nearly always required to submit.
  4. All Item Numbers required by the ASC X12 Dental Claim Implementation guide, are marked REQUIRED.  Everything else is used under the conditions described in the implementation guide.  Providers are responsible for knowing when certain Situational data elements are required.
  5. All data edits on electronic data will conform to the edits outlined in the HIPAA implementation guide and addenda.
  6. COB information should follow the CDT Standard and not be entered at the line level.  You may indicate the amount the primary carrier paid in the “Remarks” field (Item # 35).
  7. Claim forms must be type-written (computer generated, typed, machine generated, etc.). Hand-written claim forms may be returned.

 

Implementation Issues:

  • Providers may begin submitting the 2012 Dental Claim Form (J430) to Utah Payers beginning July 1, 2012.
  • A dual-use period for the 2012 Dental Claim Form (J430) and the 2006 Dental Claim Form (J400) will extend from July 1, 2012 to March 31, 2014.
  • Effective April 1, 2014, Utah Payers may only accept the 2012 Dental Claim Form (J430).

 


DATA OUTSIDE OF FORM NUMBERED ITEMS
 

Claim Frequency Code – REQUIRED

Placement – Top Right First Line, Right Justified

 

X12 Crosswalk

2300 CLM05-3

Valid Values are:

1-ORIGINAL (Admit thru Discharge Claim)

6-CORRECTED (Adjustment of Prior Claim)

7-REPLACEMENT (Replacement of Prior Claim)

8-VOID (Void/Cancel of Prior Claim)

 

Original Reference Number – Payer Claim Control Number

REQUIRED when the claim frequency code other than “original” is used

Placement – Top Right Second Line, Right Justified

 

X12 Crosswalk

2300 REF02 (REF01 = F8)

 

Claim Filing Indicator Code – REQUIRED

Placement – Top Right Third Line Right Justified

X12 Crosswalk

2000B SBR09

Please see the X12 005010X224 for valid values

 

SECTION: Header Information
 

Item Number 1 – TYPE OF TRANSACTION – REQUIRED

Statement of Actual Services

No X12 Crosswalk

Request for Predetermination/Preauthorization
X12 Crosswalk

2300 CLM19

EPSDT/Title XIX
X12 Crosswalk

2300 CLM12

 Valid Value 01 Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health     

 Assessment Program (CHAP)

 

Item Number 2 – PREDETERMINATION/PREAUTHORIZATION NUMBER

This number is assigned by the payer.

 

X12 Crosswalk

If Statement of actual services in Item Number 1 is marked and a number is in Item 2, crosswalk the
number:
      

2300 REF02 (REF01 = G1)


SECTION: Insurance Company/Dental Benefits Plan Information

Item Number 3 – COMPANY/PLAN NAME, ADDRESS, CITY, STATE, ZIP CODE – REQUIRED

 

X12 Crosswalk

2010BB NM103, N3, N4 (Payer Name / Payer Address / Payer City, State, Zip Code) 

Payer Responsibility Sequence Number

Place the code in the first position of item #3

 

X12 Crosswalk              

2000B SBR01

Valid Values are:

P – Primary

S – Secondary

TTertiary

 

 

SECTION: Other Coverage

 

Item Number 4OTHER DENTAL OR MEDICAL COVERAGE – REQUIRED

If No (Skip items 5-11), If either box is marked (Complete items 5-11 for the applicable benefit plan), If Both (Complete items 5-11 for dental only)

 

No X12 Crosswalk

Item Number 5NAME OF POLICYHOLDER/SUBSCRIBER IN #4

(Last Name, First Name, Middle Initial, Suffix)
 

X12 Crosswalk
      2330A NM103, NM104, NM105, NM107 (Last, First, Middle, Suffix)

Item Number 6DATE OF BIRTH

(MM/DD/CCYY)

 

No X12 Crosswalk

Item Number 7GENDER

M (Male) F (Female)

 

No X12 Crosswalk

 

Item Number 8 – POLICYHOLDER/SUBSCRIBER ID

(SSN OR ID#)

X12 Crosswalk

2330A NM109

 

Item Number 9PLAN/GROUP NUMBER

 

X12 Crosswalk

2320 SBR03
 


Item Number 10 – PATIENT’S RELATIONSHIP TO PERSON NAMED IN #5

(Self, Spouse, Dependent, Other)
 

X12 Crosswalk
2320 SBR02

Valid Values are:

18 – Self

01 – Spouse

76 – Dependant

21 – Unknown

 

Item Number 11OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME, ADDRESS, CITY, STATE, ZIP CODE

 

X12 Crosswalk
2330B NM103, N3, N4 (Name / Address/ City, State, Zip Code)
 

 

SECTION: Policyholder/Subscriber Information

 

Item Number 12 POLICYHOLDER/SUBSCRIBER NAME ADDRESS, CITY, STATE, ZIP CODE – REQUIRED             

(Last Name, First Name, Middle Initial, Suffix)

X12 Crosswalk

2010BA NM103, NM104, NM105, NM107 (Last, First, Middle Initial, Suffix)

2010BA N3, N4 (Address/ City, State, Zip)

 

Item Number 13 DATE OF BIRTH – REQUIRED

(MM/DD/CCYY)
 

X-12 Crosswalk

2010BA DMG02

 

Item Number 14 GENDER

(M, F)

REQUIRED when the patient is the same person as the subscriber or when known

 

X-12 Crosswalk

2010BA DMG03 Output “U” if no box marked.

 

Item Number 15 – POLICYHOLDER/SUBSCRIBER ID – REQUIRED

(SSN OR ID#)

Enter the unique identifying number assigned by the third-party payer (e.g. insurance company) to the person named in item #12.

X-12 Crosswalk

2010BA NM109

 

Item Number 16. PLAN/GROUP NUMBER

For Insurance Company Named in #3

 

X-12 Crosswalk

2000B SBR03

 

Item Number 17.EMPLOYER NAME

For Insurance Company Named in #3

 

No X12 Crosswalk

 

SECTION: Patient Information

 

Item Number 18 RELATIONSHIP TO POLICYHOLDER/SUBSCRIBER IN #12 ABOVE

If self is checked in item number 18 then patient = subscriber (bypass item number 19 through 22). If anything else, then patient ≠ subscriber.

 

X12 Crosswalk

If the Patient = subscriber, then

2000B SBR02 18=Self

If the patient ≠ subscriber, then

2000C PAT01 01=Spouse, 19=Dependent Child, 21=Unknown                    

Item Number 19 – RESERVED FOR FUTURE USE
Leave blank and skip to item #20. (#19 was previously used to report “Student Status.”)

No X12 Crosswalk

Item Number 20 – NAME – REQUIRED

(LAST, FIRST, MIDDLE INITIAL, SUFFIX)

 

X-12 Crosswalk

2010CA NM103, NM104, NM105, NM107 (Last, First, Middle Initial, Suffix)

2010CA N3, N4 (Address / City, State, Zip Code

 

Item Number 21. – DATE OF BIRTH – REQUIRED

(MM/DD/CCYY)

 

X-12 Crosswalk

2010CA DMG02

 

Item Number 22. – GENDER

(M, F)

REQUIRED when known
 

X-12 Crosswalk

2010CA DMG03 Output “U” if no box marked.

 


Item Number 23. – PATIENT ID/ACCOUNT #

(Assigned by Dentist)

This number should be unique to the claim. It is used for financial reconciliation purposes.

This item is strongly recommended.

 

X-12 Crosswalk

2300 CLM01 (Maximum number of characters to be supported is 20)

 

 

SECTION:  Record of Services Provided

 

Item Number 24 – PROCEDURE DATE

(MM/DD/CCYY)

REQUIRED when “Statement of Actual Services” is checked in Item Number 1.

Coordination of Benefit amounts are not carried in this box. Please see item #35.

 

X-12 Crosswalk

2300 DTP03 (DTP01 = 472) Claim level date is sent for performed services (Not used for predetermination)

2400 DTP03 (DTP01 = 472) When a line service date is different than the claim level date

 

Item Number 25 – AREA OF ORAL CAVITY
 

X-12 Crosswalk

2400 SV304

 

Item Number 26 -TOOTH SYSTEM

 

X-12 Crosswalk

       2400 TOO01
Valid Value:

JP – National Standard Tooth Numbering System

 

Item Number 27 – TOOTH NUMBER(S) OR LETTER(S)

 

X-12 Crosswalk

2400 TOO02

 

This box is also used to convey supernumerary teeth (See instructions provided by ADA

in the CDT).
 

Supernumerary Teeth

X12 Crosswalk      

2300 NTE02

 

 

Item Number 28 – TOOTH SURFACE 
 

X-12 Crosswalk

2400 TOO03

 

Item Number 29 – PROCEDURE CODE – REQUIRED 
 

X-12 Crosswalk

2400 SV301-2

 

Item Number 29aDIAGNOSIS CODE POINTER(S)

The letter(s) from item 34 that identify the diagnosis code(s) applicable to the dental procedure. The primary diagnosis pointer is listed first.

 

X-12 Crosswalk

2400 SV311-1 through SV311-4

 

Item Number 29b – Quantity

 

The number of times (01-99) the procedure identified in item 29 is delivered to the patient on the date of service shown on item 24. The default value is “01.”

 

X-12 Crosswalk

2400 SV306

 

Item Number 30 – DESCRIPTION

 

X-12 Crosswalk

2400 SV301-7

 

Item Number 31 – FEE

Usual and customary charge. REQUIRED when “Statement of Actual Services” is checked in

Item Number 1

X-12 Crosswalk

2400 SV302

 

Item Number 31a OTHER FEE(s)

(State tax and other charges imposed by regulatory bodies)

X-12 Crosswalk

2400 AMT02

Item Number 32 TOTAL FEE

Amounts placed here are those allowed in payer to provider contract, otherwise not used (example sales Tax amount). The sum of all fees from lines in #31, plus any fee(s) entered in item #31a. Coordination of Benefit amounts are not carried in this box. Please see item #35.

 

X-12 Crosswalk

2300 CLM02

 

 

SECTION:  Missing Teeth Information

 

Item Number 33 MISSING TEETH INFORMATION

An “X” is marked on the number of the missing tooth – for identifying missing permanent dentition only.

 

X-12 Crosswalk

2300 DN201 (DN202 = M)

 

Item Number 34. – DIAGNOSIS CODE LIST QUALIFIER

Diagnosis code source:

 

B = ICD-9-CM

AB = ICD-10-CM (For dates of service on or after October 1, 2014)

 

This information is REQUIRED when the diagnosis may have an impact on the adjudication of the claim.

X12 Crosswalk

2300 HI01-1

 

Item Number 34a – DIAGNOSIS CODE(S)

May enter up to four applicable diagnosis codes after each letter (A. – D.). The primary diagnosis code is entered adjacent to the letter “A.”

 

This information is REQUIRED when the diagnosis may have an impact on the adjudication of the claim.

 

X12 Crosswalk

2300 HI01-2 through HI04-2

 

Item Number 35. – REMARKS

This box is used to convey additional information including coordination of benefits (See instructions provided by ADA in the CDT).
 

Coordination of BenefitsREQUIRED when prior insurance has processed this claim.

COB Reporting is available ONLY at the Claim Level on paper.

COB Reporting is available at the claim and line level on electronic claims.

 

2320 CAS01 – CAS19.  The Group COB code, Adjustment Reason Code and the amount should be reported.

REQUIRED when prior insurance has processed this claim.
 

COB Example:

Prior payer(s) payment (T) 400.00

Patient Responsibility (PR:01) 100.00

Prior payer(s) contractual write-off or adjustment amounts (CO:45) 67.00

Please use the x12 reason codes for the adjustments returned in the

Electronic or Paper EOB.
 


 

X12 Crosswalk
2320 AMT02 (Prior Payer Amount Paid – AMT01 = D)

2320 AMT02 (Remaining Patient Liability – AMT01 = EAF)

2320 CAS02, CAS03 (Adjustment Amounts – CAS01 = CO, CR, OA, PI)

 

SECTION: Authorizations

Item Number 36 – Patient Consent – REQUIRED

X12 Crosswalk

2300 CLM09

Valid Values are:

I – Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes             

Y Yes Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

 


Item Number 37 Subscriber’s Signature – REQUIRED

(Assignment of Benefits)
 

X12 Crosswalk

2300 CLM08

Valid Values are:

Y – Yes

N No

W – Not Applicable (when patient refuses to assign benefits)
 

 

SECTION:  Ancillary Claim/Treatment Information

 

Item Number 38 PLACE OF TREATMENT – REQUIRED
For Provider’s Office Box and ECF Box mark “X”

For Hospital Box or Other Box enter X12 valid value (See Code Source 237 -www.cms.hhs.gov/placeofservicecodes)

X12 Crosswalk

2300 CLM 05 -1

Valid Values are: 

11 – Provider Office

12 – Home

21 – Inpatient Hospital

22 – Outpatient Hospital

31 –Skilled Nursing Facility

32 – Nursing Facility

Other – Use appropriate code (Place of Service Codes for Professional Claims).

Item Number 39 NUMBER OF ENCLOSURES (00 TO 99)
Y” or “N” to indicate whether or not there are enclosures of any type included with the claim submission (e.g., radiographs, oral images, models).

 

X12 Crosswalk

2300 PWK01, PWK02, PWK05, PWK06

 

Item Number 40 – IS TREATMENT FOR ORTHODONTICS? – REQUIRED

 

NO (Skip Items 41-42)

No X12 Crosswalk

YES (Complete Items 41-42)

No X12 Crosswalk

 

Item Number 41- DATE APPLIANCE PLACED

(MM/DD/CCYY)

X12 Crosswalk

2300 DTP03 (DTP01 = 452)

 

Item Number 42 MONTHS OF TREATMENT REMAINING

 

X12 Crosswalk

2300 DN102

 


Item Number 43 REPLACEMENT OF PROSTHESIS?

No, Yes (Complete Item 44)
 

No X12 Crosswalk 

2400 SV305

Valid values are:

R Replacement

 

Item Number 44 DATE PRIOR PLACEMENT

(MM/DD/CCYY)
REQUIRED when box #43 is marked “Yes”.

 

X12 Crosswalk

2400 DTP03 (DTP01 = 441)

 

Item Number 45 – TREATMENT RESULTING FROM

(Occupational Illness/Injury, Auto accident, Other Accident)
 

X12 Crosswalk

2300 CLM11-1, CLM11-2

Valid values are:

EM – Employment (Occupational illness/injury)

AA – Auto

OA – Other Accident

For those claims that require a Property and Casualty claim number (event number), place in top section of box.

 

X12 Crosswalk

2010CA REF02 (REF01 = Y4)

 

 

 

Item Number 46 – DATE OF ACCIDENT

(MM/DD/YY)

X12 Crosswalk

2300 DTP03 (DTP01 = 439)

 

Item Number 47 – AUTO ACCIDENT STATE

Required if CLM-11 has value of “AA”

 

X12 Crosswalk

2300 CLM11- 4

 

SECTION:  Billing Dentist or Dental Entity

 

Item Number 48 – NAME, ADDRESS, CITY, STATE, ZIP CODE – REQUIRED
Must be the physical location of Service as identified in payer contract (Cannot be a PO Box).
 

Billing Provider Name
X12 Crosswalk
2010AA NM103, NM104, NM105, NM107 (Last, First, Middle, Suffix)

 

Billing Provider Address

X12 Cross Walk

2010AA N301

 

Billing Provider City, State, Zip Code

X12 Cross Walk

2010AA N401, N402, N403

 

Item Number 49 – NPI – REQUIRED
Enter the NPI that corresponds with the information for the Billing Provider sent in item #48

X12 Crosswalk

2010AA NM109 (NM108 = XX)

Item Number 50 – LICENSE NUMBER
 

X12 Crosswalk

2010 AA REF02 (REF01 = OB)

 

Item Number 51 – SSN OR TIN – REQUIRED
 

X12 Crosswalk

2010AA REF02 (REF01 = EI or SY)

 

Item Number 52 – PHONE NUMBER

X12 Crosswalk

2010AA PER04 
 

Item Number 52a – ADDITIONAL PROVIDER ID

X12 Crosswalk

NOT USED

 

 

SECTION: Treating Dentist And Treatment Location Information

 

Item Number 53 – TREATING DENTIST – REQUIRED

Print name of Treating Dentist (Rendering).

 

X12 Crosswalk

2310B NM103, NM104, NM105, NM107 (NM101 = 82)

 

Item Number 54 – NPI – REQUIRED

 

X12 Crosswalk

2310B NM109 (NM108 = XX)
 

Item Number 55 – LICENSE NUMBER

 

X12 Crosswalk

2010AA REF02 (REF01 = OB)

 

Item Number 56 – ADDRESS, CITY, STATE, ZIP
 

X12 Crosswalk

Address

X12 Cross Walk

2010AA N301

 

City, State, Zip Code

X12 Cross Walk

2010AA N401, N402, N403

 

 

Item Number 56a – PROVIDER SPECIALTY CODE

May be required by payers for contract matching (Taxonomy).
 

X12 Crosswalk

2310B PRV03 (PRV02 = ZZ)
 

Item Number 57 – PHONE

X12 Crosswalk
2010AA PER04

 

Item Number 58 -ADDITIONAL PROVIDER ID

 

X12 Crosswalk
NOT USED

 

 

History: (MM/DD/YY)

 

Original

A 3.1

A* 3.2

A* 3.4

A* 3.5

ORIGINATION DATE

09/29/2009

4/4/2011

11/25/2013

 

 

APPROVAL DATE

12/02/2009

5/18/2011

1/9/2014

 

 

EFFECTIVE DATE

01/02/2010

6/18/2011

2/5/2014

 

 

* A = Amendment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX A

Claim Form

X12 Crosswalk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix B

Claim Form

Billing Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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