[ X12 Examples ]
Com1 Software 837D Dental Claims Example
Posted: Thursday, August 15 2024 1:02:29 PM
Com1 Software, Inc.
(330) 653-3771
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837D Dental Claims Example
837D Dental Claims source file.
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *080319*2327*U*00501*002721171*0*P*:~ GS*HC*SENDER*RECEIVER*20080319*2327*27211711*X*005010X224A2~ ST*837*0002~ BHT*0019*00*0123*19990210*1023*CH~ NM1*41*2*TEST BILLING SERVICE*****46*567890~ PER*IC*Steve*TE*7126149999~ NM1*40*2*INSURANCE COMPANY*****46*999996666~ HL*1**20*1~ NM1*85*2*DENTAL GROUP*****34*587654321~ N3*234 SEAWAY ST~ N4*MIAMI*FL*33111~ NM1*PE*2*DENTAL GROUPS*****34*587654321~ N3*234 SEAWAY ST~ N4*MIAMI*FL*33111~ HL*2*1*22*1~ SBR*P*****6***CI~ NM1*IL*1*SMITH*JANE****MI*JS00111223333~ NM1*PR*2*INSURANCE COMPANY*****PI*999996666~ HL*3*2*23*0~ PAT*19~ NM1*QC*1*SMITH*TED~ N3*236 N MAIN ST~ N4*MIAMI*FL*33413~ DMG*D8*19730501*M~ CLM*26403774*200***11::1*Y**Y*Y~ DTP*472*D8*19990209~ REF*D9*111222333444~ NM1*82*1*KILDARE*BEN****34*123454321~ PRV*PE*ZZ*122300000N~ LX*1~ SV3*AD:D3320*200****1~ TOO*JP*5*F:O~ SE*29*0002~ GE*1*27211711~ IEA*1*002721171~
Basic Inline
Base Mapping for the 837D
********* 837D Claim Submission Configuration ************************************************** X12TRANSACTIONTYPE=837D VERSION=5010 KEYHEADERFIELD=HL,,,20 KEYFIELD=SBR KEYLINEFIELD=SV3 FIELD=SUBID,16,NM1,IL,2,9 FIELD=PRIMARYCOV,1,SBR,P,2,1 FIELD=SECONDARYCOV,1,SBR,S,2,1 FIELD=TERTIARYCOV,1,SBR,T,2,1 FIELD=SUBLNAME,32,NM1,IL,2,3,,SUBID FIELD=SUBFNAME,32,NM1,IL,2,4,,SUBID FIELD=SUBMI,1,NM1,IL,2,5,,SUBID FIELD=SUBADDR1,30,N3,,,1,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBADDR2,30,N3,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBCITY,30,N4,,,1,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBST,2,N4,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBZIP,10,N4,,,3,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBSEX,1,DMG,,,3,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBMSTATUS,1,DMG,,,4,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBDOB,10,DMG,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBREL,3,SBR,,,2,,SUBID FIELD=SUBORDER,3,SBR,,,1,,SUBID FIELD=PAYERID,16,NM1,PR,2,9,,SUBID FIELD=PAYERNAME,32,NM1,PR,2,3,,PAYERID FIELD=PAYERADDR1,30,N3,,,1,,PAYERID FIELD=PAYERADDR2,30,N3,,,2,,PAYERID FIELD=PAYERCITY,30,N4,,,1,,PAYERID FIELD=PAYERST,2,N4,,,2,,PAYERID FIELD=PAYERZIP,10,N4,,,3,,PAYERID FIELD=PRIMARYSUBID,16,NM1,IL,2,9,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBLNAME,32,NM1,IL,2,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBFNAME,32,NM1,IL,2,4,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBMI,1,NM1,IL,2,5,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBADDR1,30,N3,,,1,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBADDR2,30,N3,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBCITY,30,N4,,,1,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBST,2,N4,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBZIP,10,N4,,,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBSEX,1,DMG,,,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBMSTATUS,1,DMG,,,4,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBDOB,10,DMG,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBREL,3,SBR,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYPAYERID,16,NM1,PR,2,9,,PRIMARYCOV FIELD=PRIMARYPAYERNAME,32,NM1,PR,2,3,,PRIMARYCOV FIELD=PRIMARYPAYERADDR1,30,N3,,,1,,PRIMARYCOV FIELD=PRIMARYPAYERADDR2,30,N3,,,2,,PRIMARYCOV FIELD=PRIMARYPAYERCITY,30,N4,,,1,,PRIMARYCOV FIELD=PRIMARYPAYERST,2,N4,,,2,,PRIMARYCOV FIELD=PRIMARYPAYERZIP,10,N4,,,3,,PRIMARYCOV FIELD=SECONDARYSUBID,16,NM1,IL,2,9,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBLNAME,32,NM1,IL,2,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBFNAME,32,NM1,IL,2,4,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBMI,1,NM1,IL,2,5,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBADDR1,30,N3,,,1,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBADDR2,30,N3,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBCITY,30,N4,,,1,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBST,2,N4,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBZIP,10,N4,,,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBSEX,1,DMG,,,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBMSTATUS,1,DMG,,,4,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBDOB,10,DMG,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBREL,3,SBR,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYPAYERID,16,NM1,PR,2,9,,SECONDARYCOV FIELD=SECONDARYPAYERNAME,32,NM1,PR,2,3,,SECONDARYCOV FIELD=SECONDARYPAYERADDR1,30,N3,,,1,,SECONDARYCOV FIELD=SECONDARYPAYERADDR2,30,N3,,,2,,SECONDARYCOV FIELD=SECONDARYPAYERCITY,30,N4,,,1,,SECONDARYCOV FIELD=SECONDARYPAYERST,2,N4,,,2,,SECONDARYCOV FIELD=SECONDARYPAYERZIP,10,N4,,,3,,SECONDARYCOV FIELD=TERTIARYSUBID,16,NM1,IL,2,9,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBLNAME,32,NM1,IL,2,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBFNAME,32,NM1,IL,2,4,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBMI,1,NM1,IL,2,5,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBADDR1,30,N3,,,1,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBADDR2,30,N3,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBCITY,30,N4,,,1,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBST,2,N4,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBZIP,10,N4,,,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBSEX,1,DMG,,,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBMSTATUS,1,DMG,,,4,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBDOB,10,DMG,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBREL,3,SBR,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYPAYERID,16,NM1,PR,2,9,,TERTIARYCOV FIELD=TERTIARYPAYERNAME,32,NM1,PR,2,3,,TERTIARYCOV FIELD=TERTIARYPAYERADDR1,30,N3,,,1,,TERTIARYCOV FIELD=TERTIARYPAYERADDR2,30,N3,,,2,,TERTIARYCOV FIELD=TERTIARYPAYERCITY,30,N4,,,1,,TERTIARYCOV FIELD=TERTIARYPAYERST,2,N4,,,2,,TERTIARYCOV FIELD=TERTIARYPAYERZIP,10,N4,,,3,,TERTIARYCOV FIELD=PATID,16,NM1,QC,2,9 FIELD=PATLNAME,32,NM1,QC,2,3 FIELD=PATFNAME,32,NM1,QC,2,4 FIELD=PATMI,1,NM1,QC,2,5 FIELD=PATADDR1SUBADDR1,30,N3,,,1,,PATLNAME FIELD=PATADDR2SUBADDR2,30,N3,,,2,,PATLNAME FIELD=PATCITY,30,N4,,,1,,PATLNAME FIELD=PATST,2,N4,,,2,,PATLNAME FIELD=PATZIP,10,N4,,,3,,PATLNAME FIELD=PATSEX,1,DMG,,,3,,PATLNAME FIELD=PATMSTAT,1,DMG,,,4,,PATLNAME FIELD=PATDOB,10,DMG,,,2,,PATLNAME FIELD=PATREL,1,PAT,,,2,,PATLNAME FIELD=CLAIMID,20,CLM,,,1,,SUBID FIELD=CLAIMAMT,20,CLM,,,2,,SUBID FIELD=PROVSIGNATUREONFILE,4,CLM,,,7,,SUBID FIELD=PROVACCEPTASSIGNMENTCODE,4,CLM,,,8,,SUBID FIELD=BENEFITINDICATOR,4,CLM,,,9,,SUBID FIELD=RELEASEOFINFORMATION,2,CLM,,,10,,SUBID FIELD=RELATEDCAUSE,20,CLM,,,12,,SUBID FIELD=FACILITYCODEVALUE,3,CLM,,,5,1,SUBID FIELD=FACILITYCODEQUALIFIER,3,CLM,,,5,2,SUBID FIELD=FREQUENCYTYPECODE,3,CLM,,,5,3,SUBID FIELD=MEDICALRECORDNUMBER,10,REF,EA,,3,,SUBID FIELD=PROCEDURE1,16,SV3,,,1,2,SUBID,,,1 FIELD=DPROC1,10,SV3,,,2,2,SUBID,,,1 FIELD=DMODA1,3,SV3,,,2,3,SUBID,,,1 FIELD=DMODB1,3,SV3,,,2,4,SUBID,,,1 FIELD=DMODC1,3,SV3,,,2,5,SUBID,,,1 FIELD=DMODD1,3,SV3,,,2,6,SUBID,,,1 FIELD=DAMT1,10,SV3,,,3,,SUBID,,,1 FIELD=DUNITS1,10,SV3,,,3,,SUBID,,,1 FIELD=DDOS1,10,DTP,472,2,3,,SUBID,,,1 FIELD=PROCEDURE2,16,SV3,,,1,2,SUBID,,,2 FIELD=DPROC2,10,SV3,,,2,2,SUBID,,,2 FIELD=DMODA2,3,SV3,,,2,3,SUBID,,,2 FIELD=DMODB2,3,SV3,,,2,4,SUBID,,,2 FIELD=DMODC2,3,SV3,,,2,5,SUBID,,,2 FIELD=DMODD2,3,SV3,,,2,6,SUBID,,,2 FIELD=DAMT2,10,SV3,,,3,,SUBID,,,2 FIELD=DUNITS2,10,SV3,,,3,,SUBID,,,2 FIELD=DDOS2,10,DTP,472,2,3,,SUBID,,,2 FIELD=PROCEDURE3,16,SV3,,,1,2,SUBID,,,3 FIELD=DPROC3,10,SV3,,,2,2,SUBID,,,3 FIELD=DMODA3,3,SV3,,,2,3,SUBID,,,3 FIELD=DMODB3,3,SV3,,,2,4,SUBID,,,3 FIELD=DMODC3,3,SV3,,,2,5,SUBID,,,3 FIELD=DMODD3,3,SV3,,,2,6,SUBID,,,3 FIELD=DAMT3,10,SV3,,,3,,SUBID,,,3 FIELD=DUNITS3,10,SV3,,,3,,SUBID,,,3 FIELD=DDOS3,10,DTP,472,2,3,,SUBID,,,3 FIELD=PROCEDURE4,16,SV3,,,1,2,SUBID,,,4 FIELD=DPROC4,10,SV3,,,2,2,SUBID,,,4 FIELD=DMODA4,3,SV3,,,2,3,SUBID,,,4 FIELD=DMODB4,3,SV3,,,2,4,SUBID,,,4 FIELD=DMODC4,3,SV3,,,2,5,SUBID,,,4 FIELD=DMODD4,3,SV3,,,2,6,SUBID,,,4 FIELD=DAMT4,10,SV3,,,3,,SUBID,,,4 FIELD=DUNITS4,10,SV3,,,3,,SUBID,,,4 FIELD=DDOS4,10,DTP,472,2,3,,SUBID,,,4 FIELD=PROCEDURE5,16,SV3,,,1,2,SUBID,,,5 FIELD=DPROC5,10,SV3,,,2,2,SUBID,,,5 FIELD=DMODA5,3,SV3,,,2,3,SUBID,,,5 FIELD=DMODB5,3,SV3,,,2,4,SUBID,,,5 FIELD=DMODC5,3,SV3,,,2,5,SUBID,,,5 FIELD=DMODD5,3,SV3,,,2,6,SUBID,,,5 FIELD=DAMT5,10,SV3,,,3,,SUBID,,,5 FIELD=DUNITS5,10,SV3,,,3,,SUBID,,,5 FIELD=DDOS5,10,DTP,472,2,3,,SUBID,,,5 FIELD=PROCEDURE6,16,SV3,,,1,2,SUBID,,,6 FIELD=DPROC6,10,SV3,,,2,2,SUBID,,,6 FIELD=DMODA6,3,SV3,,,2,3,SUBID,,,6 FIELD=DMODB6,3,SV3,,,2,4,SUBID,,,6 FIELD=DMODC6,3,SV3,,,2,5,SUBID,,,6 FIELD=DMODD6,3,SV3,,,2,6,SUBID,,,6 FIELD=DAMT6,10,SV3,,,3,,SUBID,,,6 FIELD=DUNITS6,10,SV3,,,3,,SUBID,,,6 FIELD=DDOS6,10,DTP,472,2,3,,SUBID,,,6 FIELD=PROCEDURE7,16,SV3,,,1,2,SUBID,,,7 FIELD=DPROC7,10,SV3,,,2,2,SUBID,,,7 FIELD=DMODA7,3,SV3,,,2,3,SUBID,,,7 FIELD=DMODB7,3,SV3,,,2,4,SUBID,,,7 FIELD=DMODC7,3,SV3,,,2,5,SUBID,,,7 FIELD=DMODD7,3,SV3,,,2,6,SUBID,,,7 FIELD=DAMT7,10,SV3,,,3,,SUBID,,,7 FIELD=DUNITS7,10,SV3,,,3,,SUBID,,,7 FIELD=DDOS7,10,DTP,472,2,3,,SUBID,,,7 FIELD=PROCEDURE8,16,SV3,,,1,2,SUBID,,,8 FIELD=DPROC8,10,SV3,,,2,2,SUBID,,,8 FIELD=DMODA8,3,SV3,,,2,3,SUBID,,,8 FIELD=DMODB8,3,SV3,,,2,4,SUBID,,,8 FIELD=DMODC8,3,SV3,,,2,5,SUBID,,,8 FIELD=DMODD8,3,SV3,,,2,6,SUBID,,,8 FIELD=DAMT8,10,SV3,,,3,,SUBID,,,8 FIELD=DUNITS8,10,SV3,,,3,,SUBID,,,8 FIELD=DDOS8,10,DTP,472,2,3,,SUBID,,,8 FIELD=PROCEDURE9,16,SV3,,,1,2,SUBID,,,9 FIELD=DPROC9,10,SV3,,,2,2,SUBID,,,9 FIELD=DMODA9,3,SV3,,,2,3,SUBID,,,9 FIELD=DMODB9,3,SV3,,,2,4,SUBID,,,9 FIELD=DMODC9,3,SV3,,,2,5,SUBID,,,9 FIELD=DMODD9,3,SV3,,,2,6,SUBID,,,9 FIELD=DAMT9,10,SV3,,,3,,SUBID,,,9 FIELD=DUNITS9,10,SV3,,,3,,SUBID,,,9 FIELD=DDOS9,10,DTP,472,2,3,,SUBID,,,9 FIELD=PROCEDURE10,16,SV3,,,1,2,SUBID,,,10 FIELD=DPROC10,10,SV3,,,2,2,SUBID,,,10 FIELD=DMODA10,3,SV3,,,2,3,SUBID,,,10 FIELD=DMODB10,3,SV3,,,2,4,SUBID,,,10 FIELD=DMODC10,3,SV3,,,2,5,SUBID,,,10 FIELD=DMODD10,3,SV3,,,2,6,SUBID,,,10 FIELD=DAMT10,10,SV3,,,3,,SUBID,,,10 FIELD=DUNITS10,10,SV3,,,3,,SUBID,,,10 FIELD=DDOS10,10,DTP,472,2,3,,SUBID,,,10 FIELD=BILLINGPROVIDERID,16,NM1,85,2,9,,SUBID FIELD=BILLINGPROVIDERNAME,32,NM1,85,2,3,,SUBID FIELD=BILLINGPROVIDERADDR1,30,N3,,,1,,BILLINGPROVIDERNAME FIELD=BILLINGPROVIDERADDR2,30,N3,,,2,,BILLINGPROVIDERNAME FIELD=BILLINGPROVIDERCITY,30,N4,,,1,,BILLINGPROVIDERNAME FIELD=BILLINGPROVIDERST,2,N4,,,2,,BILLINGPROVIDERNAME FIELD=BILLINGPROVIDERZIP,10,N4,,,3,,BILLINGPROVIDERNAME FIELD=PAYTOPROVIDERID,16,NM1,87,2,9,,SUBID FIELD=PAYTOPROVIDERNAME,32,NM1,87,2,3,,SUBID FIELD=PAYTOPROVIDERADDR1,30,N3,,,1,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERADDR2,30,N3,,,2,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERCITY,30,N4,,,1,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERST,2,N4,,,2,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERZIP,10,N4,,,3,,PAYTOPROVIDERNAME FIELD=PAYTOPLAID,16,NM1,PE,2,9,,SUBID FIELD=PAYTOPLANAME,32,NM1,PE,2,3,,SUBID FIELD=PAYTOPLAADDR1,30,N3,,,1,,PAYTOPLANAME FIELD=PAYTOPLAADDR2,30,N3,,,2,,PAYTOPLANAME FIELD=PAYTOPLACITY,30,N4,,,1,,PAYTOPLANAME FIELD=PAYTOPLAST,2,N4,,,2,,PAYTOPLANAME FIELD=PAYTOPLAZIP,10,N4,,,3,,PAYTOPLANAME FIELD=SUBMITTERID,16,NM1,41,2,9 FIELD=SUBMITTERNAME,32,NM1,41,2,3,,SUBMITTERID FIELD=SUBMITTERADDR1,30,N3,,,1,,SUBMITTERNAME FIELD=SUBMITTERADDR2,30,N3,,,2,,SUBMITTERNAME FIELD=SUBMITTERCITY,30,N4,,,1,,SUBMITTERNAME FIELD=SUBMITTERST,2,N4,,,2,,SUBMITTERNAME FIELD=SUBMITTERZIP,10,N4,,,3,,SUBMITTERNAME SEGMENT=1,CLM SEGMENT=1,NM1,QC SEGMENT=1,NM1,IL SEGMENT=1,NM1,82 SEGMENT=2,SV3