CreateClaimEdi Field Map (837D)
With "claimType": "dental", POST /api/SharpRcm/v1/CreateClaimEdi builds an 837D (005010X224A2). This page lists every field of the request and the loop, segment and element it is written to. The 837P field map explains how to read the tables and describes the shared building blocks (provider, address, contact, date, reference, adjustment).
The request model is the same for every claim type, so a dental service line uses procedureCount rather than serviceUnitCount, and teeth go in teethInformation[]. Fields the 837D has no place for are listed under Not sent.
The tables below are generated from a test that builds an 837D from a request with every field filled in and confirms each value lands where the table says. They cannot drift from what the API sends.
Request
Fields on the request itself. They build the envelope and the submitter and receiver loops.
| JSON field | 837 | Notes |
|---|---|---|
submitterName | 1000A NM1*41 NM103 | |
submitterId | 1000A NM1*41 NM109 | Also ISA06 and GS02 when envelop.isa06 / envelop.gs02 are empty. |
submitterContactName | 1000A PER PER02 | |
submitterPhone | 1000A PER PER04 | PER03 is always TE. |
receiverName | 1000B NM1*40 NM103 | Used only when envelop.receiverName is empty. |
transactionControlNumber | ST ST02 | Also SE02. |
bhtControlNumber | BHT BHT03 | |
groupControlNumber | GS GS06 | Also GE02. |
envelop.isa01 | ISA ISA01 | |
envelop.isa02 | ISA ISA02 | Pad to 10. |
envelop.isa03 | ISA ISA03 | |
envelop.isa04 | ISA ISA04 | Pad to 10. |
envelop.isa05 | ISA ISA05 | |
envelop.isa06 | ISA ISA06 | Pad to 15. Falls back to submitterId. |
envelop.isa07 | ISA ISA07 | |
envelop.isa08 | ISA ISA08 | Pad to 15. |
envelop.isa13 | ISA ISA13 | Nine digits. Also IEA02. |
envelop.isa14 | ISA ISA14 | |
envelop.isa15 | ISA ISA15 | P production, T test. |
envelop.gs01 | GS GS01 | HC when empty. |
envelop.gs02 | GS GS02 | Falls back to submitterId. |
envelop.gs03 | GS GS03 | Also 1000B NM109 when envelop.receiverId is empty. |
envelop.gs08 | GS GS08 | Also ST03. Send 005010X224A2, or leave it empty and it is set from claimType. |
envelop.receiverName | 1000B NM1*40 NM103 | |
envelop.receiverId | 1000B NM1*40 NM109 | |
envelop.bht02 | BHT BHT02 | |
envelop.bht06 | BHT BHT06 |
Billing provider (2000A, 2010AA)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
billingProviderEditorView.nm1Data.entityCode | 2010AA NM1*85 NM101 | Filled in as 85. |
billingProviderEditorView.nm1Data.entityType | 2010AA NM1*85 NM102 | |
billingProviderEditorView.nm1Data.lastName | 2010AA NM1*85 NM103 | |
billingProviderEditorView.nm1Data.firstName | 2010AA NM1*85 NM104 | |
billingProviderEditorView.nm1Data.middleName | 2010AA NM1*85 NM105 | |
billingProviderEditorView.nm1Data.suffix | 2010AA NM1*85 NM107 | |
billingProviderEditorView.nm1Data.npi | 2010AA NM1*85 NM109 | |
billingProviderEditorView.nm1Data.taxonomyCode | 2000A PRV*BI PRV03 | |
billingProviderEditorView.address1, address2, city, state, zip | 2010AA N3, N4 (address) | |
billingProviderEditorView.secondaryIdentifiers[].qualifierCode | 2010AA REF*EI REF01 | Only EI / SY (the first one, the tax id) and 0B / 1G are written. otherRefValue is not sent. Send EI. |
billingProviderEditorView.secondaryIdentifiers[].refValue | 2010AA REF*EI REF02 | |
billingProviderEditorView.secondaryIdentifiers[].qualifierCode | 2010AA REF*0B REF01 | Send 0B. |
billingProviderEditorView.secondaryIdentifiers[].refValue | 2010AA REF*0B REF02 | |
billingProviderEditorView.contact1 | 2010AA PER (contact) | Written when contactType1 and contactInfo1 are set. |
billingProviderEditorView.contact2 | 2010AA PER (contact) | Written when contactType1 and contactInfo1 are set. |
Pay-to address and plan (2010AB, 2010AC)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
payToAddressView.entityType | 2010AB NM1*87 NM102 | The loop is written when address1 is set. NM101 is always 87. |
payToAddressView.address1, address2, city, state, zip | 2010AB N3, N4 (address) | |
payToPlanView.organizationName | 2010AC NM1*PE NM103 | The loop is written when organizationName is set. |
payToPlanView.primaryIdentifier | 2010AC NM1*PE NM109 | |
payToPlanView.address1, address2, city, state, zip | 2010AC N3, N4 (address) | |
payToPlanView.secondaryIdentifierType | 2010AC REF*2U REF01 | Send 2U. |
payToPlanView.secondaryIdentifier | 2010AC REF*2U REF02 | |
payToPlanView.taxIdNumber | 2010AC REF*EI REF02 |
Subscriber (2000B, 2010BA)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
subscriberEditorView.payerResponsibility | 2000B SBR01 | relationshipCode is written exactly as sent: 18 when the subscriber is the patient, empty when patientEditorView is used. |
subscriberEditorView.relationshipCode | 2000B SBR02 | |
subscriberEditorView.policyNumber | 2000B SBR03 | |
subscriberEditorView.groupName | 2000B SBR04 | |
subscriberEditorView.insuranceTypeCode | 2000B SBR05 | |
subscriberEditorView.claimFilingIndicator | 2000B SBR09 | |
subscriberEditorView.entityType | 2010BA NM1*IL NM102 | NM108 is always MI. |
subscriberEditorView.lastName | 2010BA NM1*IL NM103 | |
subscriberEditorView.firstName | 2010BA NM1*IL NM104 | |
subscriberEditorView.middleName | 2010BA NM1*IL NM105 | |
subscriberEditorView.suffix | 2010BA NM1*IL NM107 | |
subscriberEditorView.subscriberPrimaryIdent | 2010BA NM1*IL NM109 | |
subscriberEditorView.address1, address2, city, state, zip | 2010BA N3, N4 (address) | |
subscriberEditorView.birthDay | 2010BA DMG02 | |
subscriberEditorView.gender | 2010BA DMG03 | |
subscriberEditorView.ssn | 2010BA REF*SY REF02 | |
subscriberEditorView.casualtyClaimNumber | 2010BA REF*Y4 REF02 |
Payer (2010BB)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
payerEditerView.organizationName | 2010BB NM1*PR NM103 | Note the spelling: payerEditerView. |
payerEditerView.payerIdentifier | 2010BB NM1*PR NM109 | Routes the claim. NM108 is always PI. |
payerEditerView.address1, address2, city, state, zip | 2010BB N3, N4 (address) | |
payerEditerView.taxIdNumber | 2010BB REF*EI REF02 | |
payerEditerView.claimOfficeNumber | 2010BB REF*FY REF02 | |
payerEditerView.naicCode | 2010BB REF*NF REF02 | |
payerEditerView.locationNumber | 2010BB REF*LU REF02 | |
payerEditerView.providerCommericalNumber | 2010BB REF*G2 REF02 |
Patient (2000C, 2010CA)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
patientEditorView.relationshipCode | 2000C PAT PAT01 | Creates the patient loop. Without it nothing in patientEditorView is written. |
patientEditorView.lastName | 2010CA NM1*QC NM103 | NM102 is always 1. |
patientEditorView.firstName | 2010CA NM1*QC NM104 | |
patientEditorView.middleName | 2010CA NM1*QC NM105 | |
patientEditorView.suffix | 2010CA NM1*QC NM107 | |
patientEditorView.address1, address2, city, state, zip | 2010CA N3, N4 (address) | |
patientEditorView.birthDay | 2010CA DMG02 | |
patientEditorView.gender | 2010CA DMG03 | |
patientEditorView.casualtyClaimNumber | 2010CA REF*Y4 REF02 |
Claim (2300)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
claimEditorView.patientControlNumber | 2300 CLM CLM01 | Your claim id. It comes back on the 277CA and 835. |
claimEditorView.totalClaimChargeAmt | 2300 CLM CLM02 | Must equal the sum of the line charges. |
claimEditorView.placeOfService | 2300 CLM CLM05-1 | CLM05-2 is always B. |
claimEditorView.claimFreqCode | 2300 CLM CLM05-3 | 1 original, 7 replacement, 8 void. |
claimEditorView.providerSignatureOnFile | 2300 CLM CLM06 | |
claimEditorView.planParticipationCode | 2300 CLM CLM07 | |
claimEditorView.benefitsAssignmentCertIndicator | 2300 CLM CLM08 | |
claimEditorView.releaseOfInfoCode | 2300 CLM CLM09 | |
claimEditorView.relatedCausesCode1 | 2300 CLM11-1 | |
claimEditorView.relatedCausesCode2 | 2300 CLM11-2 | |
claimEditorView.accidentState | 2300 CLM11-4 | |
claimEditorView.accidentCountry | 2300 CLM11-5 | |
claimEditorView.specialProgramIndicator | 2300 CLM CLM12 | |
claimEditorView.claimSubmissionReasonCode | 2300 CLM CLM19 | PB for a predetermination of benefits. |
claimEditorView.delayReasonCode | 2300 CLM CLM20 | |
claimEditorView.dateAccident | 2300 DTP*439 (date) | |
claimEditorView.appliancePlacement | 2300 DTP*452 (date) | Orthodontic banding date. |
claimEditorView.service | 2300 DTP*472 (date) | A claim-level date of service; lines can carry their own. |
claimEditorView.dateRepricerReceived | 2300 DTP*050 (date) | |
claimEditorView.orthoTotalMonthsTreatment.orthoTreatmentMonths | 2300 DN101 | Written when any of the three is set. |
claimEditorView.orthoTotalMonthsTreatment.orthoTreatmentRemainingMonths | 2300 DN102 | |
claimEditorView.orthoTotalMonthsTreatment.orthoTreatmentIndicator | 2300 DN104 | |
claimEditorView.toothStatuses[].toothNumber | 2300 DN201 | Missing or to-be-extracted teeth, one DN2 each. Written when both are set. |
claimEditorView.toothStatuses[].toothStatus | 2300 DN202 | |
claimEditorView.supplementalInfos[].reportTypeCode | 2300 PWK01 | Up to 10. PWK05 is AC when the transmission code is BM, EL, EM, FX or FT. |
claimEditorView.supplementalInfos[].transmissionCode | 2300 PWK02 | |
claimEditorView.supplementalInfos[].attachmentControlNumber1 | 2300 PWK06 | |
claimEditorView.contractInfo.contractTypeCode | 2300 CN101 | Written when contractTypeCode is set. |
claimEditorView.contractInfo.contractAmt | 2300 CN102 | |
claimEditorView.contractInfo.contractPercent | 2300 CN103 | |
claimEditorView.contractInfo.contractCode | 2300 CN104 | |
claimEditorView.contractInfo.contractTermsPercent | 2300 CN105 | |
claimEditorView.contractInfo.contractVersionIdent | 2300 CN106 | |
claimEditorView.patientPaidAmount.qualifierCode | 2300 AMT*F5 AMT01 | Filled in as F5. |
claimEditorView.patientPaidAmount.amount | 2300 AMT*F5 AMT02 | |
claimEditorView.refPredeterminationOfBenefitsIdent | 2300 REF*G3 (reference) | |
claimEditorView.refSpecialPayment | 2300 REF*4N (reference) | |
claimEditorView.refOriginalReference | 2300 REF*F8 (reference) | The payer's claim number, for a replacement or void. |
claimEditorView.refReferralNumber | 2300 REF*9F (reference) | |
claimEditorView.refPriorAuthorization | 2300 REF*G1 (reference) | |
claimEditorView.refRepricedClaimReference | 2300 REF*9A (reference) | |
claimEditorView.refAdjRepricedClaimRerence | 2300 REF*9C (reference) | |
claimEditorView.refTraceNumber | 2300 REF*D9 (reference) | |
claimEditorView.fileInformations[] | 2300 K3 K301 | Up to 10. |
claimEditorView.notes[].referenceCode | 2300 NTE*ADD NTE01 | Claim notes, one NTE each. Send ADD. |
claimEditorView.notes[].noteText | 2300 NTE*ADD NTE02 | |
claimEditorView.diagnosisCodes[].diagnosisType | 2300 HI01-1 | One HI composite per code, in diagnosisOrder order: ABK for the principal, ABF for the rest. Send ABK. |
claimEditorView.diagnosisCodes[].diagnosisCode | 2300 HI01-2 | |
claimEditorView.diagnosisCodes[].diagnosisType | 2300 HI02-1 | Send ABF. |
claimEditorView.diagnosisCodes[].diagnosisCode | 2300 HI02-2 | |
claimEditorView.repricing.pricingMethodology | 2300 HCP01 | Written when pricingMethodology and repricedAllowedAmt are set. |
claimEditorView.repricing.repricedAllowedAmt | 2300 HCP02 | |
claimEditorView.repricing.repriceSavingsAmt | 2300 HCP03 | |
claimEditorView.repricing.repricingOrgIdent | 2300 HCP04 | |
claimEditorView.repricing.rate | 2300 HCP05 | |
claimEditorView.repricing.groupCode | 2300 HCP06 | |
claimEditorView.repricing.patientGroupAmt | 2300 HCP07 | |
claimEditorView.repricing.rejectReasonCode | 2300 HCP13 | |
claimEditorView.repricing.complianceCode | 2300 HCP14 | |
claimEditorView.repricing.exceptionCode | 2300 HCP15 | |
claimEditorView.referringProvider | 2310A NM1*DN, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DN. |
claimEditorView.primaryCareProvider | 2310A NM1*P3, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as P3. |
claimEditorView.renderingProvider | 2310B NM1*82, PRV*PE, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as 82. |
claimEditorView.serviceFacility.organizationName | 2310C NM1*77 NM103 | Written when organizationName is set. NM108 is XX when primaryIdentifier (the NPI) is set. |
claimEditorView.serviceFacility.primaryIdentifier | 2310C NM1*77 NM109 | |
claimEditorView.serviceFacility.address1 | 2310C N301 | |
claimEditorView.serviceFacility.address2 | 2310C N302 | |
claimEditorView.serviceFacility.city | 2310C N401 | |
claimEditorView.serviceFacility.state | 2310C N402 | |
claimEditorView.serviceFacility.zip | 2310C N403 | |
claimEditorView.serviceFacility.secondaryIdentifiers[].qualifierCode | 2310C REF*G2 REF01 | Send G2. |
claimEditorView.serviceFacility.secondaryIdentifiers[].refValue | 2310C REF*G2 REF02 | |
claimEditorView.serviceFacility.secondaryIdentifiers[].otherRefValue | 2310C REF*G2 REF04 | |
claimEditorView.assistantSurgeon | 2310D NM1*DD, PRV*AS, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DD. |
claimEditorView.supervisingProvider | 2310E NM1*DQ, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DQ. |
Other payers (2320, 2330A-H)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
secondaryEditorView[].otherSubscriber.payerResponsibility | 2320 SBR01 | payerResponsibility and relationshipCode are both required; without them the whole entry is dropped. |
secondaryEditorView[].otherSubscriber.relationshipCode | 2320 SBR02 | |
secondaryEditorView[].otherSubscriber.policyNumber | 2320 SBR03 | |
secondaryEditorView[].otherSubscriber.groupName | 2320 SBR04 | |
secondaryEditorView[].otherSubscriber.insuranceTypeCode | 2320 SBR05 | |
secondaryEditorView[].otherSubscriber.claimFilingIndicator | 2320 SBR09 | |
secondaryEditorView[].lineAdjustments[] | 2320 CAS (adjustment) | Claim-level adjustments, one entry per group code. |
secondaryEditorView[].payerPaidAmt.amountQualCode | 2320 AMT*D AMT01 | Filled in as D. |
secondaryEditorView[].payerPaidAmt.monetaryAmt | 2320 AMT*D AMT02 | |
secondaryEditorView[].nonCoveredAmount.amountQualCode | 2320 AMT*A8 AMT01 | Filled in as A8. |
secondaryEditorView[].nonCoveredAmount.monetaryAmt | 2320 AMT*A8 AMT02 | |
secondaryEditorView[].amountOwed.amountQualCode | 2320 AMT*EAF AMT01 | Filled in as EAF. |
secondaryEditorView[].amountOwed.monetaryAmt | 2320 AMT*EAF AMT02 | |
secondaryEditorView[].benefitsAssignmentCertIndicator | 2320 OI03 | Written when benefitsAssignmentCertIndicator is set. |
secondaryEditorView[].releaseOfInfoCode | 2320 OI06 | |
secondaryEditorView[].reimbursementRate | 2320 MOA01 | Medicare outpatient adjudication. Written when any is set. |
secondaryEditorView[].hcpcsPayableAmt | 2320 MOA02 | |
secondaryEditorView[].claimPaymentRemarkCode1 | 2320 MOA03 | |
secondaryEditorView[].claimPaymentRemarkCode2 | 2320 MOA04 | |
secondaryEditorView[].claimPaymentRemarkCode3 | 2320 MOA05 | |
secondaryEditorView[].claimPaymentRemarkCode4 | 2320 MOA06 | |
secondaryEditorView[].claimPaymentRemarkCode5 | 2320 MOA07 | |
secondaryEditorView[].nonPayableProfessionalCompBilledAmt | 2320 MOA09 | |
secondaryEditorView[].otherSubscriber.entityType | 2330A NM1*IL NM102 | N4 needs city, state and zip all set. |
secondaryEditorView[].otherSubscriber.lastName | 2330A NM1*IL NM103 | |
secondaryEditorView[].otherSubscriber.firstName | 2330A NM1*IL NM104 | |
secondaryEditorView[].otherSubscriber.middleName | 2330A NM1*IL NM105 | |
secondaryEditorView[].otherSubscriber.suffix | 2330A NM1*IL NM107 | |
secondaryEditorView[].otherSubscriber.subscriberPrimaryIdent | 2330A NM1*IL NM109 | |
secondaryEditorView[].otherSubscriber.address1 | 2330A N301 | |
secondaryEditorView[].otherSubscriber.address2 | 2330A N302 | |
secondaryEditorView[].otherSubscriber.city | 2330A N401 | |
secondaryEditorView[].otherSubscriber.state | 2330A N402 | |
secondaryEditorView[].otherSubscriber.zip | 2330A N403 | |
secondaryEditorView[].otherSubscriber.ssn | 2330A REF*SY REF02 | |
secondaryEditorView[].payerEditorView.organizationName | 2330B NM1*PR NM103 | payerIdentifier is what each line's adjudications[].otherPayerPrimaryIdentifier must match. |
secondaryEditorView[].payerEditorView.payerIdentifier | 2330B NM1*PR NM109 | |
secondaryEditorView[].payerEditorView.address1 | 2330B N301 | |
secondaryEditorView[].payerEditorView.address2 | 2330B N302 | |
secondaryEditorView[].payerEditorView.city | 2330B N401 | |
secondaryEditorView[].payerEditorView.state | 2330B N402 | |
secondaryEditorView[].payerEditorView.zip | 2330B N403 | |
secondaryEditorView[].payerEditorView.adjudicationPaymentDate.dateQualifier | 2330B DTP*573 DTP01 | Filled in as 573. |
secondaryEditorView[].payerEditorView.adjudicationPaymentDate.dateValue | 2330B DTP*573 DTP03 | |
secondaryEditorView[].payerEditorView.additionalPayerIdentifier | 2330B REF*2U REF02 | |
secondaryEditorView[].payerEditorView.taxIdNumber | 2330B REF*EI REF02 | |
secondaryEditorView[].payerEditorView.claimOfficeNumber | 2330B REF*FY REF02 | |
secondaryEditorView[].payerEditorView.naicCode | 2330B REF*NF REF02 | |
secondaryEditorView[].payerEditorView.priorAuthNumber | 2330B REF*G1 REF02 | |
secondaryEditorView[].payerEditorView.referralNumber | 2330B REF*9F REF02 | |
secondaryEditorView[].payerEditorView.signalCode | 2330B REF*T4 REF02 | |
secondaryEditorView[].payerEditorView.predeterminationOfBenefits | 2330B REF*G3 REF02 | |
secondaryEditorView[].payerEditorView.origionalRefNumber | 2330B REF*F8 REF02 | |
secondaryEditorView[].referringProvider | 2330C NM1*DN, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DN. |
secondaryEditorView[].primaryCareProvider | 2330C NM1*P3, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as P3. |
secondaryEditorView[].renderingProvider | 2330D NM1*82, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as 82. 2330D carries no taxonomy. |
secondaryEditorView[].supervisingProvider | 2330E NM1*DQ, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DQ. |
secondaryEditorView[].billingProviderEditorView | 2330F NM1*85, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as 85. Its address and contacts are not sent. |
secondaryEditorView[].serviceFacility.organizationName | 2330G NM1*77 NM103 | Written when organizationName is set. 2330G carries no address. |
secondaryEditorView[].serviceFacility.primaryIdentifier | 2330G NM1*77 NM109 | |
secondaryEditorView[].serviceFacility.secondaryIdentifiers[].qualifierCode | 2330G REF*G2 REF01 | Send G2. |
secondaryEditorView[].serviceFacility.secondaryIdentifiers[].refValue | 2330G REF*G2 REF02 | |
secondaryEditorView[].serviceFacility.secondaryIdentifiers[].otherRefValue | 2330G REF*G2 REF04 | |
secondaryEditorView[].assistantSurgeon | 2330H NM1*DD, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DD. 2330H carries no taxonomy. |
Service line (2400-2430)
Paths are relative to each entry in claims[].
| JSON field | 837 | Notes |
|---|---|---|
serviceLinesEditorView[].lineNumber | 2400 LX01 | |
serviceLinesEditorView[].procedureCodeQualifier | 2400 SV301-1 | |
serviceLinesEditorView[].procedureCode | 2400 SV301-2 | |
serviceLinesEditorView[].modifier1 | 2400 SV301-3 | |
serviceLinesEditorView[].modifier2 | 2400 SV301-4 | |
serviceLinesEditorView[].modifier3 | 2400 SV301-5 | |
serviceLinesEditorView[].modifier4 | 2400 SV301-6 | |
serviceLinesEditorView[].procedureDescription | 2400 SV301-7 | |
serviceLinesEditorView[].lineChargeAmount | 2400 SV302 | |
serviceLinesEditorView[].placeOfService | 2400 SV303 | |
serviceLinesEditorView[].oralCavityDesignationCode1 | 2400 SV304-1 | |
serviceLinesEditorView[].oralCavityDesignationCode2 | 2400 SV304-2 | |
serviceLinesEditorView[].oralCavityDesignationCode3 | 2400 SV304-3 | |
serviceLinesEditorView[].oralCavityDesignationCode4 | 2400 SV304-4 | |
serviceLinesEditorView[].oralCavityDesignationCode5 | 2400 SV304-5 | |
serviceLinesEditorView[].prosthesisCrownInlayCode | 2400 SV305 | |
serviceLinesEditorView[].procedureCount | 2400 SV306 | |
serviceLinesEditorView[].pointer1 | 2400 SV311-1 | |
serviceLinesEditorView[].pointer2 | 2400 SV311-2 | |
serviceLinesEditorView[].pointer3 | 2400 SV311-3 | |
serviceLinesEditorView[].pointer4 | 2400 SV311-4 | |
serviceLinesEditorView[].teethInformation[].toothCode | 2400 TOO02 | One TOO per tooth, written when toothCode is set. TOO01 is always JP (universal numbering). |
serviceLinesEditorView[].teethInformation[].toothSurfaceCode1 | 2400 TOO03-1 | |
serviceLinesEditorView[].teethInformation[].toothSurfaceCode2 | 2400 TOO03-2 | |
serviceLinesEditorView[].teethInformation[].toothSurfaceCode3 | 2400 TOO03-3 | |
serviceLinesEditorView[].teethInformation[].toothSurfaceCode4 | 2400 TOO03-4 | |
serviceLinesEditorView[].teethInformation[].toothSurfaceCode5 | 2400 TOO03-5 | |
serviceLinesEditorView[].dateService | 2400 DTP*472 (date) | |
serviceLinesEditorView[].dateEstimatedPriorPlacement | 2400 DTP*139 (date) | |
serviceLinesEditorView[].datePriorPlacement | 2400 DTP*441 (date) | |
serviceLinesEditorView[].dateAppliancePlacement | 2400 DTP*452 (date) | |
serviceLinesEditorView[].dateApplianceReplacement | 2400 DTP*446 (date) | |
serviceLinesEditorView[].dateTreatmentStart | 2400 DTP*196 (date) | |
serviceLinesEditorView[].dateTreatmentEnd | 2400 DTP*198 (date) | |
serviceLinesEditorView[].contractInfo.contractTypeCode | 2400 CN101 | Written when contractTypeCode is set. |
serviceLinesEditorView[].contractInfo.contractAmt | 2400 CN102 | |
serviceLinesEditorView[].contractInfo.contractPercent | 2400 CN103 | |
serviceLinesEditorView[].contractInfo.contractCode | 2400 CN104 | |
serviceLinesEditorView[].contractInfo.contractTermsPercent | 2400 CN105 | |
serviceLinesEditorView[].contractInfo.contractVersionIdent | 2400 CN106 | |
serviceLinesEditorView[].refPredeterminationOfBenefitsIdent | 2400 REF*G3 (reference) | |
serviceLinesEditorView[].refPriorAuthorization | 2400 REF*G1 (reference) | |
serviceLinesEditorView[].refLineItemControlNumber | 2400 REF*6R (reference) | Your line id; it comes back on the 835. |
serviceLinesEditorView[].refRepricedClaimRefNumber | 2400 REF*9A (reference) | |
serviceLinesEditorView[].refAdjRepricedClaimRefNumber | 2400 REF*9C (reference) | |
serviceLinesEditorView[].refReferralNumber | 2400 REF*9F (reference) | |
serviceLinesEditorView[].salesTaxAmount.amountQualCode | 2400 AMT*T AMT01 | Filled in as T. |
serviceLinesEditorView[].salesTaxAmount.monetaryAmt | 2400 AMT*T AMT02 | |
serviceLinesEditorView[].fileInformations[] | 2400 K3 K301 | Up to 10. |
serviceLinesEditorView[].repricing.pricingMethodology | 2400 HCP01 | Written when pricingMethodology and repricedAllowedAmt are set. |
serviceLinesEditorView[].repricing.repricedAllowedAmt | 2400 HCP02 | |
serviceLinesEditorView[].repricing.repriceSavingsAmt | 2400 HCP03 | |
serviceLinesEditorView[].repricing.repricingOrgIdent | 2400 HCP04 | |
serviceLinesEditorView[].repricing.rate | 2400 HCP05 | |
serviceLinesEditorView[].repricing.groupCode | 2400 HCP06 | |
serviceLinesEditorView[].repricing.patientGroupAmt | 2400 HCP07 | |
serviceLinesEditorView[].repricing.productIdQualifier | 2400 HCP09 | |
serviceLinesEditorView[].repricing.repricedApprHcpcsCode | 2400 HCP10 | |
serviceLinesEditorView[].repricing.measurementCode | 2400 HCP11 | |
serviceLinesEditorView[].repricing.serviceUnitCount | 2400 HCP12 | |
serviceLinesEditorView[].repricing.rejectReasonCode | 2400 HCP13 | |
serviceLinesEditorView[].repricing.complianceCode | 2400 HCP14 | |
serviceLinesEditorView[].repricing.exceptionCode | 2400 HCP15 | |
serviceLinesEditorView[].renderingProvider | 2420A NM1*82, PRV*PE, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as 82. |
serviceLinesEditorView[].assistantSurgeon | 2420B NM1*DD, PRV*AS, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DD. |
serviceLinesEditorView[].supervisingProvider | 2420C NM1*DQ, REF (provider) | Written when nm1Data.lastName is set. entityCode is filled in as DQ. |
serviceLinesEditorView[].serviceFacility.organizationName | 2420D NM1*77 NM103 | Written when organizationName is set. |
serviceLinesEditorView[].serviceFacility.primaryIdentifier | 2420D NM1*77 NM109 | |
serviceLinesEditorView[].serviceFacility.address1 | 2420D N301 | |
serviceLinesEditorView[].serviceFacility.address2 | 2420D N302 | |
serviceLinesEditorView[].serviceFacility.city | 2420D N401 | |
serviceLinesEditorView[].serviceFacility.state | 2420D N402 | |
serviceLinesEditorView[].serviceFacility.zip | 2420D N403 | |
serviceLinesEditorView[].serviceFacility.secondaryIdentifiers[].qualifierCode | 2420D REF*G2 REF01 | Send G2. |
serviceLinesEditorView[].serviceFacility.secondaryIdentifiers[].refValue | 2420D REF*G2 REF02 | |
serviceLinesEditorView[].serviceFacility.secondaryIdentifiers[].otherRefValue | 2420D REF*G2 REF04 | |
serviceLinesEditorView[].adjudications[].otherPayerPrimaryIdentifier | 2430 SVD01 | One per payer that adjudicated the line. Written only when otherPayerPrimaryIdentifier is set, and it must match that payer's secondaryEditorView[].payerEditorView.payerIdentifier. |
serviceLinesEditorView[].adjudications[].serviceLinePaidAmt | 2430 SVD02 | |
serviceLinesEditorView[].adjudications[].productServiceIdQualifier | 2430 SVD03-1 | |
serviceLinesEditorView[].adjudications[].procedureCode | 2430 SVD03-2 | |
serviceLinesEditorView[].adjudications[].modifier1 | 2430 SVD03-3 | |
serviceLinesEditorView[].adjudications[].modifier2 | 2430 SVD03-4 | |
serviceLinesEditorView[].adjudications[].modifier3 | 2430 SVD03-5 | |
serviceLinesEditorView[].adjudications[].modifier4 | 2430 SVD03-6 | |
serviceLinesEditorView[].adjudications[].procedureDescription | 2430 SVD03-7 | |
serviceLinesEditorView[].adjudications[].serviceLineRevenueCode | 2430 SVD04 | |
serviceLinesEditorView[].adjudications[].paidServiceUnitCount | 2430 SVD05 | |
serviceLinesEditorView[].adjudications[].bundledLineNumber | 2430 SVD06 | |
serviceLinesEditorView[].adjudications[].lineAdjustments[] | 2430 CAS (adjustment) | One entry per group code. |
serviceLinesEditorView[].adjudications[].dateClaimPaid | 2430 DTP*573 (date) | |
serviceLinesEditorView[].adjudications[].amountOwed.amountQualCode | 2430 AMT*EAF AMT01 | Filled in as EAF. |
serviceLinesEditorView[].adjudications[].amountOwed.monetaryAmt | 2430 AMT*EAF AMT02 |
Not sent
These fields are accepted but do not appear in the 837P. Most belong to institutional or dental claims, which share the same model.
| JSON field | Why |
|---|---|
accountNumber | Replaced by the account your credentials resolve to. |
claimType | Set dental for this page's 837D. Sets GS08 and ST03 when envelop.gs08 is empty. |
envelop.isa09 | ISA09/ISA10 are the time ClaimRev builds the file. |
envelop.isa10 | ISA09/ISA10 are the time ClaimRev builds the file. |
envelop.isa11 | Taken from envelop.separators. |
envelop.isa12 | Always 00501. |
envelop.isa16 | Taken from envelop.separators. |
envelop.separators | Sets the delimiters ClaimRev writes with; *, ~, : and ^ when omitted. |
claimId | Yours to use; not part of the 837. |
sharpRcmClaimId | Internal. |
claimStatusId | Internal. |
claimText | Internal. |
claimErrors | Output only. |
receiverViewModel | The receiver (1000B) comes from envelop.receiverName / receiverName. |
submitterEditViewModel | Required, but the submitter (1000A) comes from submitterName, submitterId, submitterContactName and submitterPhone. |
*.qualifierCodeHint | Editor hints. |
*.refValueHint | Editor hints. |
*.otherRefValueHint | Editor hints. |
*.nm1Data.taxonomyCode | Written only for the billing (2000A PRV), rendering (2310B, 2420A PRV) and assistant surgeon (2310D, 2420B PRV) providers. |
billingProviderEditorView.secondaryIdentifiers[].otherRefValue | Not sent for the billing provider. |
payToAddressView.entityCode | Always 87. |
subscriberEditorView.dateOfDeath | The 837D subscriber has no PAT. |
subscriberEditorView.measurementCode | The 837D subscriber has no PAT. |
subscriberEditorView.weight | The 837D subscriber has no PAT. |
subscriberEditorView.pregnancyIndicator | The 837D subscriber has no PAT. |
subscriberEditorView.contact1 | The 837D has no subscriber contact. |
patientEditorView.dateOfDeath | The 837D patient PAT carries the relationship only. |
patientEditorView.measurementCode | The 837D patient PAT carries the relationship only. |
patientEditorView.weight | The 837D patient PAT carries the relationship only. |
patientEditorView.pregnancyIndicator | The 837D patient PAT carries the relationship only. |
patientEditorView.contact | The 837D has no patient contact. |
payerEditerView.priorAuthNumber | Use claimEditorView.refPriorAuthorization. |
payerEditerView.referralNumber | Use claimEditorView.refReferralNumber. |
payerEditerView.signalCode | Other payers (2330B) only. |
payerEditerView.origionalRefNumber | Use claimEditorView.refOriginalReference. |
payerEditerView.additionalPayerIdentifier | Other payers (2330B) only. |
payerEditerView.adjudicationPaymentDate | Other payers (2330B) only. |
payerEditerView.predeterminationOfBenefits | Use claimEditorView.refPredeterminationOfBenefitsIdent. |
claimEditorView.patientSignatureCode | Professional (837P) only. |
claimEditorView.dateOnSetOfCurrentIllness | Professional (837P) only. |
claimEditorView.dateLastXRay | Professional (837P) only. |
claimEditorView.dateDischarge | Institutional (837I) only. |
claimEditorView.dateInitialTreatment | Professional (837P) only. |
claimEditorView.dateHearingVisionRx | Professional (837P) only. |
claimEditorView.dateStartAssumedRelinqished | Professional (837P) only. |
claimEditorView.dateEndAssumedRelinqished | Professional (837P) only. |
claimEditorView.dateLastSeen | Professional (837P) only. |
claimEditorView.dateDisability | Professional (837P) only. |
claimEditorView.dateDisabilityStart | Professional (837P) only. |
claimEditorView.dateDisabilityEnd | Professional (837P) only. |
claimEditorView.dateAcuteManifestation | Professional (837P) only. |
claimEditorView.dateLastWorked | Professional (837P) only. |
claimEditorView.datePropertyCasualty | Professional (837P) only. |
claimEditorView.dateAuthorizedReturnWork | Professional (837P) only. |
claimEditorView.dateLastMenstrual | Professional (837P) only. |
claimEditorView.dateAdmissionDate | Institutional (837I) only. |
claimEditorView.dateStatementDate | Institutional (837I) only. |
claimEditorView.refClinicalLabImprovement | Professional (837P) only. |
claimEditorView.refFacilityIdNumber | Professional (837P) only. |
claimEditorView.refMedicareVersionCode | Professional (837P) only. |
claimEditorView.refMammographyCertNumber | Professional (837P) only. |
claimEditorView.refQualifiedProductsList | Not used in 837D. |
claimEditorView.refMedicalRecordIdent | Not used in 837D. |
claimEditorView.refProjectCode | Not used in 837D. |
claimEditorView.refLocationNumber | Institutional (837I) only. |
claimEditorView.refProApprovalNumber | Institutional (837I) only. |
claimEditorView.note | Use notes[]. |
claimEditorView.ambulanceTransport | Professional (837P) only. |
claimEditorView.spinalManipulation | Professional (837P) only. |
claimEditorView.ambulanceCerts | Professional (837P) only. |
claimEditorView.visionCerts | Professional (837P) only. |
claimEditorView.homeBound | Professional (837P) only. |
claimEditorView.epsdt | Not used in 837D. |
claimEditorView.diagnosisCodes[].diagnosisOrder | Sets the order of the HI composites. |
claimEditorView.diagnosisCodes[].presentOnAdmission | Institutional (837I) only. |
claimEditorView.diagnosisCodes[].procedureDate | Institutional (837I) only. |
claimEditorView.diagnosisCodes[].monitaryAmount | Institutional (837I) only. |
claimEditorView.admittingDiagnosisCode | Institutional (837I) only. |
claimEditorView.reasonForVisitDiagnosisCodes | Institutional (837I) only. |
claimEditorView.externalCauseInjDiagnosisCodes | Institutional (837I) only. |
claimEditorView.principalProcedureCode | Institutional (837I) only. |
claimEditorView.otherPrincipalProcedureCodes | Institutional (837I) only. |
claimEditorView.occurrenceSpanCodes | Institutional (837I) only. |
claimEditorView.occurrenceCodes | Institutional (837I) only. |
claimEditorView.valueInformation | Institutional (837I) only. |
claimEditorView.drgCode | Institutional (837I) only. |
claimEditorView.conditionCodes | Not used in 837D. |
claimEditorView.treatmentCodes | Institutional (837I) only. |
claimEditorView.claimCode | Institutional (837I) only. |
claimEditorView.anesthesaProcedureCode | Professional (837P) only. |
claimEditorView.anesthesaIndustryCode | Professional (837P) only. |
claimEditorView.repricing.productIdQualifier | Line-level only (HCP09). |
claimEditorView.repricing.repricedApprHcpcsCode | Line-level only (HCP10). |
claimEditorView.repricing.measurementCode | Line-level only (HCP11). |
claimEditorView.repricing.serviceUnitCount | Line-level only (HCP12). |
claimEditorView.attendingProvider | Institutional (837I) only. |
claimEditorView.operatingProvider | Institutional (837I) only. |
claimEditorView.otherOperatingProvider | Institutional (837I) only. |
claimEditorView.ambulancePickupLocation | Professional (837P) only. |
claimEditorView.ambulanceDropOffLocation | Professional (837P) only. |
secondaryEditorView[].otherSubscriber.dateOfDeath | Not part of 2330A. |
secondaryEditorView[].otherSubscriber.measurementCode | Not part of 2330A. |
secondaryEditorView[].otherSubscriber.weight | Not part of 2330A. |
secondaryEditorView[].otherSubscriber.pregnancyIndicator | Not part of 2330A. |
secondaryEditorView[].otherSubscriber.birthDay | Not part of 2330A. |
secondaryEditorView[].otherSubscriber.gender | Not part of 2330A. |
secondaryEditorView[].otherSubscriber.casualtyClaimNumber | Not part of 2330A. |
secondaryEditorView[].otherSubscriber.contact1 | Not part of 2330A. |
secondaryEditorView[].patientSignatureCode | Professional (837P) only. |
secondaryEditorView[].endStageRenalDiseasePmtAmt | Not used in 837D. |
secondaryEditorView[].inpatientAdjudication | Institutional (837I) only. |
secondaryEditorView[].payerEditorView.providerCommericalNumber | A billing-provider id (2010BB); not valid for another payer (2330B). |
secondaryEditorView[].payerEditorView.locationNumber | A billing-provider id (2010BB); not valid for another payer (2330B). |
secondaryEditorView[].payerEditorView.adjudicationPaymentDate.periodFormat | Always D8. |
secondaryEditorView[].serviceFacility.address1 | 2330G carries the name and ids only. |
secondaryEditorView[].serviceFacility.address2 | 2330G carries the name and ids only. |
secondaryEditorView[].serviceFacility.city | 2330G carries the name and ids only. |
secondaryEditorView[].serviceFacility.state | 2330G carries the name and ids only. |
secondaryEditorView[].serviceFacility.zip | 2330G carries the name and ids only. |
secondaryEditorView[].attendingProvider | Institutional (837I) only. |
secondaryEditorView[].operatingProvider | Institutional (837I) only. |
secondaryEditorView[].otherOperatingProvider | Institutional (837I) only. |
secondaryEditorView[].billingProviderEditorView.address1 | 2330F carries the name and ids only. |
secondaryEditorView[].billingProviderEditorView.address2 | 2330F carries the name and ids only. |
secondaryEditorView[].billingProviderEditorView.city | 2330F carries the name and ids only. |
secondaryEditorView[].billingProviderEditorView.state | 2330F carries the name and ids only. |
secondaryEditorView[].billingProviderEditorView.zip | 2330F carries the name and ids only. |
secondaryEditorView[].billingProviderEditorView.contact1 | 2330F carries the name and ids only. |
secondaryEditorView[].billingProviderEditorView.contact2 | 2330F carries the name and ids only. |
serviceLinesEditorView[].revenueCode | Institutional (837I) only. |
serviceLinesEditorView[].nonCoveredChargeAmount | Institutional (837I) only. |
serviceLinesEditorView[].serviceUnitMeasurementCode | Not used in SV3. |
serviceLinesEditorView[].serviceUnitCount | Use procedureCount. |
serviceLinesEditorView[].emergencyIndicator | Professional (837P) only. |
serviceLinesEditorView[].epsdtIndicator | Professional (837P) only. |
serviceLinesEditorView[].familyIndicator | Professional (837P) only. |
serviceLinesEditorView[].coPayStatusCode | Professional (837P) only. |
serviceLinesEditorView[].dmeService | Professional (837P) only. |
serviceLinesEditorView[].supplementalInfos | Not used at line level in 837D. |
serviceLinesEditorView[].dmeCertOfMedicalNecessityIndicator | Professional (837P) only. |
serviceLinesEditorView[].ambulanceTransport | Professional (837P) only. |
serviceLinesEditorView[].durableMedicalEquipmentCert | Professional (837P) only. |
serviceLinesEditorView[].ambulanceCerts | Professional (837P) only. |
serviceLinesEditorView[].hospiceIndicator | Professional (837P) only. |
serviceLinesEditorView[].dmeCondition | Professional (837P) only. |
serviceLinesEditorView[].datePrescription | Professional (837P) only. |
serviceLinesEditorView[].dateCertificationRevisionRecert | Professional (837P) only. |
serviceLinesEditorView[].dateBeginTherapy | Professional (837P) only. |
serviceLinesEditorView[].dateLastCertification | Professional (837P) only. |
serviceLinesEditorView[].dateLastSeen | Professional (837P) only. |
serviceLinesEditorView[].dateRecentHemoglobin | Professional (837P) only. |
serviceLinesEditorView[].dateRecentSerumCreatine | Professional (837P) only. |
serviceLinesEditorView[].dateShipped | Professional (837P) only. |
serviceLinesEditorView[].dateLastXRay | Professional (837P) only. |
serviceLinesEditorView[].dateInitialTreatment | Professional (837P) only. |
serviceLinesEditorView[].ambulancePatientCount | Professional (837P) only. |
serviceLinesEditorView[].obstretricAnesthesiaAddUnits | Professional (837P) only. |
serviceLinesEditorView[].testResults | Professional (837P) only. |
serviceLinesEditorView[].refRepricedLineItemRefNumber | The 837D line uses refRepricedClaimRefNumber (9A). |
serviceLinesEditorView[].refAdjRepricedLineItemRefNumber | The 837D line uses refAdjRepricedClaimRefNumber (9C). |
serviceLinesEditorView[].refMammographyCertNumber | Professional (837P) only. |
serviceLinesEditorView[].refCliaNumber | Professional (837P) only. |
serviceLinesEditorView[].refCliaNumberFacilityIdent | Professional (837P) only. |
serviceLinesEditorView[].refImmunizationBatchNumber | Professional (837P) only. |
serviceLinesEditorView[].postageClaimedAmt | Professional (837P) only. |
serviceLinesEditorView[].serviceTaxAmount | Not used in 837D. |
serviceLinesEditorView[].miscTaxes | Not used in 837D. |
serviceLinesEditorView[].lineNote | Professional (837P) only. |
serviceLinesEditorView[].thirdPartyNote | Not used in 837D. |
serviceLinesEditorView[].purchasedServiceInfo | Professional (837P) only. |
serviceLinesEditorView[].drugIdentification | Not used in 837D. |
serviceLinesEditorView[].purchasedServiceProvider | Professional (837P) only. |
serviceLinesEditorView[].operatingProvider | Institutional (837I) only. |
serviceLinesEditorView[].otherOperatingProvider | Institutional (837I) only. |
serviceLinesEditorView[].orderingProvider | Professional (837P) only. |
serviceLinesEditorView[].referringProvider | Not used at line level in 837D. |
serviceLinesEditorView[].primaryCareProvider | Not used at line level in 837D. |
serviceLinesEditorView[].ambulancePickupLocation | Professional (837P) only. |
serviceLinesEditorView[].ambulanceDropOffLocation | Professional (837P) only. |
serviceLinesEditorView[].formIdent | Professional (837P) only. |
serviceLinesEditorView[].adjudications[].modifier5 | SVD03 carries four modifiers. |
serviceLinesEditorView[].adjudications[].dateClaimPaid.periodFormat | Always D8. |