Data Exchange Workgroup Dental Subworkgroup Dental Claims White Paper

Transcription

1 Data Exchange Workgroup Dental Subworkgroup Dental Claims White Paper White Paper: Mapping of the ADA Dental Claim Form ( 2012 American Dental Association) to the ASC X12N X224A2 Health Care Claim: Dental (837D) June 13, 2018

2 Workgroup for Electronic Data Interchange 1984 Isaac Newton Square, Suite 304, Reston, VA T: /F: Workgroup for Electronic Data Interchange, All Rights Reserved CONTENT Disclaimer I. Purpose II. III. IV. Scope Description of Mapping Acknowledgements List of Appendices Appendix A. ADA Dental Claim Form ( 2012 American Dental Association Appendix B. Mapping of the ADA Dental Claim Form to the ASC X12N X224A2 Health Care Claim: Dental (837D) 1

3 Disclaimer This document is Copyright 2018 by The Workgroup for Electronic Data Interchange (WEDI). It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. If you require legal advice, you should consult with an attorney. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by the Workgroup for Electronic Data Interchange. The listing of an organization does not imply any sort of endorsement and the Workgroup for Electronic Data Interchange takes no responsibility for the products, tools, and Internet sites listed. The existence of a link or organizational reference in any of the following materials should not be assumed as an endorsement by the Workgroup for Electronic Data Interchange (WEDI), or any of the individual workgroups or subworkgroups of the WEDI Strategic National Implementation Process (WEDI SNIP). Document is for Education and Awareness Use Only Intellectual Property Citations The intellectual property in Appendix B (the mapping appendix) of this document belongs to X12. The link to X12 s Intellectual Property (IP) use can be found at: The intellectual property in the Appendix A (the dental claim form) belongs to the American Dental Association ( 2012 American Dental Association). The form illustrated in full in this Appendix, and portions illustrated in other chapters, are used with permission. This form is cited as the ADA Dental Claim Form or ADA Form within this White Paper. 2

4 Mapping of the ADA Dental Claim Form ( 2012 American Dental Association) to the ASC X12N X224A2 Health Care Claim: Dental (837D) I. Purpose The purpose of this white paper is to provide guidance on how to populate the ASC X12N X224A2 Health Care Claim: Dental (837D) electronic transaction from the data reported on the ADA Dental Claim Form ( 2012 American Dental Association). The ASC X12N X224A2 Health Care Claim: Dental (837D) is the current HIPAA adopted version of the electronic dental claim transaction. II. Scope The scope of this paper is to identify the mapping of the ADA Dental Claim Form to the ASC X12N X224A2 Health Care Claim: Dental (837D). III. Description of Mapping The ADA Dental Claim Form (Appendix A) was developed for dental providers and office staff to submit claims to be reimbursed by payers for services rendered. With today s focus on conducting claims and other administrative transactions electronically, it is important to have the ability to map the data from the ADA Dental Claim Form ( 2012 American Dental Association) to the ASC X12N X224A2 Health Care Claim: Dental (837D) electronic transaction. The Mapping of the ADA Dental Claim Form to the ASC X12N X224A2 Health Care Claim: Dental (837D) (Appendix B) provides the information a user needs to populate the electronic transaction with the data from the ADA Dental Claim Form. 3

5 Instructional Guide: In order to use this white paper, use Appendix A as a starting reference point. For example, under the Header box in the top left corner of Appendix A there is the Number 1. Number 2 for Predetermination/Preauthorization Number is immediately under Number 1. The chart in Appendix B maps the data elements on the ADA Dental Claim Form to the corresponding loops and segments in the ASC X12N X224A2 Health Care Claim: Dental (837D) electronic transaction. 4

6 For more information, refer to: The ADA Dental Claim Form ( 2012 American Dental Association) ( (The ASC X12N X224A2 Health Care Claim: Dental (837D) Technical Report Type 3 ( IV. Acknowledgements The co-chairs would like to extend our special thanks to all members of the WEDI Dental Workgroup with particular note to the following individuals. Tom Drinkard, Delta Dental of Virginia Frank Pokorny, American Dental Association Eric Kirnbauer, Tesia Clearinghouse, LLC. 5

7 Appendix A: ADA Dental Claim Form ( 2012 American Dental Association). In order to preserve the user-friendliness of the document, a title Appendix A does not appear in any of the margins. Consider this page as a cover page. The ADA Dental Claim Form is reprinted with the permission of the American Dental Association. See the American Dental Association s requested form name and copyright citations at the top and bottom right-hand side of the form image. 6

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9 Appendix B: Mapping of the ADA Dental Claim Form ( 2012 American Dental Association) to the ASC X12N X224 Health Care Claim: Dental (837D) The following is the mapping of the ADA Dental Claim Form to the ASC X12N X224A2 Health Care Claim: Dental (837D). Location on ADA Dental Claim Form ADA Dental Claim Form Header Statement of actual services Request for Predetermination/Preauthorization EPSDT / Title XIX Predetermination/Preauthorization Number Insurance Company/Dental Benefit Plan Company/Plan Name, Address, City, State, Zip Code Dental? Medical? D Electronic Transaction Loop, Segment, and Element 2300 CLM / (empty) 2300 CLM / PB 2300 CLM REF (REF01 = 'G1') Prior Authorization ID 2300 REF (REF01 = 'G3') Predetermination ID 2010BB NM BB N BB N BB N BB N BB N SBR (is present) 2320 SBR (is present) 8

10 Location on ADA Dental Claim Form ADA Dental Claim Form Header Name of Policyholder/Subscriber in #4 (Last, First, Middle Initial, Suffix) Date of Birth Gender Policyholder/Subscriber ID (SSN or ID#) Plan / Group Number Patient's Relationship to Person named in #5 Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code Policyholder/Subscriber (For Insurance Company Named in #3) Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code Policyholder/Subscriber (For Insurance Company Named in #3) Policyholder/Subscriber (For Insurance Company Named in #3) Gender D Electronic Transaction Loop, Segment, and Element 2330A NM A NM A NM A NM N/A N/A 2330A NM SBR SBR B NM B N B N B N B N B N BA NM BA NM BA NM BA NM BA N BA N BA N BA N BA N Date of Birth 2010BA DMG BA DMG

11 Location on ADA Dental Claim Form ADA Dental Claim Form Header Policyholder/Subscriber (For Insurance Company Named in #3) Policyholder/Subscriber ID (SSN or ID#) Policyholder/Subscriber (For Insurance Company Named in #3) Plan / Group Number Policyholder/Subscriber (For Insurance Company Named in #3) Employer Name Patient Relationship to Primary Policyholder/Subscriber in #12 Above D Electronic Transaction Loop, Segment, and Element 2010BA NM BA SBR N/A 19 Reserved for Future Use N/A Patient Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code Patient Date of Birth Patient Gender Patient Patient ID/Account # (Assigned by Dentist) Procedure Date Area of Oral Cavity 2010CA PAT BA SBR CA NM CA NM CA NM CA NM CA N CA N CA N CA N CA N CA DMG CA DMG CLM DTP (DTP01 = 472) 2400 DTP (DTP01 = 472) 2400 SV

12 Location on ADA Dental Claim Form a 29b ADA Dental Claim Form Header Tooth System Tooth Number(s) or Letter(s) Tooth Surface Procedure Code Sales Tax Note when using CDT Code D9985: CDT Code D9985 is recorded on any unused line (1 through 10) in the ' section of the form. NOTE: Billing entities may record sales tax in different Diag Pointer Qty Description Sales Tax Note when using CDT Code D9985: Enter Sales Tax. Fee D Electronic Transaction Loop, Segment, and Element 2400 TOO TOO TOO TOO TOO TOO TOO SV Sales Tax Note when using CDT Code D9985: CDT Code D9985 is recorded on any unused line (1 through 10) in the Record of Services Provided' section of the form. NOTE: Billing entities may record sales tax in different 2400 SV SV SV SV SV SV SV

13 Location on ADA Dental Claim Form 31a 32 ADA Dental Claim Form Header Other Fees NOTE: Do not include sales tax in 31a when reported on a separate service line with CDT Code D9985. Total Fee 33 Missing Teeth 34 Diagnosis Code List Qualifier 34a (A) 34a (B,C, or D) Diagnosis Code (Primary Diagnosis) Diagnosis Code D Electronic Transaction Loop, Segment, and Element 2300 CLM DN (DN202 = M) 2300 HI HI HI HI HI HI HI HI Remarks 2300 NTE Authorizations - Release of Patient/Guardian 2300 CLM Signature Authorizations - Release of N/A Date Authorizations - Assignment of Benefits 2300 CLM Subscriber Signature Authorizations - Assignment of Benefits Date N/A CLM Place of Treatment 39 Enclosures (Y or N) 2300 PWK

14 Location on ADA Dental Claim Form ADA Dental Claim Form Header Is Treatment for Orthodontics? (No) Is Treatment for Orthodontics? (Yes) Date Appliance Placed Orthodontic Treatment Months Count Replacement of Prosthesis? (Yes) Replacement of Prosthesis? (No) Date of Prior Placement Treatment Resulting From Occupational illness/injury Treatment Resulting From Auto Accident Treatment Resulting From Other Accident Date of Accident Auto Accident State D Electronic Transaction Loop, Segment, and Element 2300 DN1 (is absent) 2300 DN1 (is present) 2300 DTP (DTP01 = 452) 2300 DN SV (SV305 = 'R') 2400 SV (SV305 = 'I') 2400 DTP (DTP01 = 441) 2300 CLM (CLM11-1 = 'EM') 2300 CLM (CLM11-2 = 'EM') 2300 CLM (CLM11-1 = 'AA') 2300 CLM (CLM11-2 = 'AA') 2300 CLM (CLM11-1 = 'OA') 2300 CLM (CLM11-2 = 'OA') 2300 DTP (DTP01 = '439') 2300 CLM

15 Location on ADA Dental Claim Form a ADA Dental Claim Form Header Billing Dentist or Dental Entity Name, Address, City, State, Zip Code Billing Dentist or Dental Entity NPI Billing Dentist or Dental Entity License Number Billing Dentist or Dental Entity SSN or TIN Billing Dentist or Dental Entity Phone Number Billing Dentist or Dental Entity Additional Provider ID Treating Dentist and Treatment Location Signed (Treating Dentist) Treating Dentist and Treatment Location Date Treating Dentist and Treatment Location NPI D Electronic Transaction Loop, Segment, and Element 2010AA NM AA NM AA NM AA NM AA N AA N AA N AA N AA N AA NM AA REF (REF01 = '0B') 2010AA REF (REF01 = 'EI') 2010AA REF (REF01 = 'SY') 2010AA PER (PER03 = 'TE') 2010AA PER (PER05 = 'TE') 2010AA PER (PER07 = 'TE') 2010AA REF (REF01 = '1G') 2010BB REF (REF01 = 'G2') 2010BB REF (REF01 = 'LU') 2300 CLM (CLM06 = 'Y') N/A 2310B NM

16 Location on ADA Dental Claim Form a ADA Dental Claim Form Header Treating Dentist and Treatment Location License Number Treating Dentist and Treatment Location Address, City, State, Zip Code Treating Dentist and Treatment Location Provider Specialty Code Treating Dentist and Treatment Location Phone Number Treating Dentist and Treatment Location Additional Provider ID D Electronic Transaction Loop, Segment, and Element 2310B REF (REF01 = '0B') 2310C NM C NM C NM C NM C N C N C N C N C N A PRV B PRV AA PER (PER03 = 'TE') 2010AA PER (PER05 = 'TE') 2010AA PER (PER07 = 'TE') 2310B PRV A PRV