This page includes technical information about E-Claims.

Also see:

• E-Claims Errors
• Medical E-Claims

Limited information about paper claims is also included on this page. For detailed information, see ADA Claim Forms. Most information is only applicable for claims sent within the United States. For information on Canadian claims, see Canada Claims.

Claim Format

Electronic claims are sent and received using the standard EDI X12 837 data format. As of January 1, 2012, all electronic claims should be sent using the 5010 format. The 4010 format should no longer be used. See https://www.cms.gov/medicare/coding/icd10/downloads/versions5010d0faqs.pdf

If you are currently using the 4010 format, use the following steps to update to the 5010 format:

• Edit your Clearinghouses to use the 5010 format.
• Update your Practice address to include the full 9-digit zip code within your Open Dental database.
• Monitor your reports for dropped claims or other problems.

Information in subsequent sections of this page pertains to the 5010 format only.

Claim Addresses

Clinic addresses determine the address and phone information for the practice sent or printed on a Claim. If there is no clinic attached to the claim, the address in Practice Setup is used.

There are three address and phone number options for claims: Physical Treating, Billing, and Pay To. The Billing and Pay To address and phone numbers are only needed if different than the Physical Treating Address and main phone number. Physical Treating and Billing addresses cannot be PO Boxes due to regulatory guidelines. Below is the order in which the Practice Setup and Clinic addresses, and phone numbers are used on e-claims versus printed Claims.

A Site's Place of Service address may also be sent on e-claims (loop 2310C) and printed claims (box 54 and 56). See Site List, Technical Details.

E-Claims

On e-claims there is an address and phone number for the billing provider (loop 2010AA, segments N3 and N4) and address for the pay-to provider (loop 2010AB, segments N3 and N4). Loop 2010AB is only included if the Practice Setup or Clinic, Pay To Address is entered. The address and phone number used from the Practice Setup and Clinic are determined based on the order below.

Billing Provider Address (loop 2010AA, segments N3 and N4)	Billing Provider Phone Number	Pay-To Provider Address (loop 2010AB, segments N3 and N4)
Billing Address of Clinic if Use on Claims is checked Billing Address of Practice if Use on Claims is checked Physical Treating Address of Clinic Physical Treating Address of Practice	Billing Address Phone of Practice if Use on Claims is checked Default Clinic Phone Default Practice Phone	Pay To Address of Clinic Pay To Address of Practice

Printed Claims

On printed claim forms there is an address and phone number for the billing and treating dentist. The treating dentist address (box 56) and treating dentist phone number (box 57) will always use the Physical Treating Address and default phone number of the Practice or Clinic. The address and phone number for the billing dentist (box 48 and 52) from the Practice Setup and Clinic are determined based on the order below.

Billing Dentist Address (box 48)	Billing Dentist Phone Number (box 52)
Pay To Address of Clinic Pay To Address of Practice Billing Address of Clinic if Use on Claims is checked Billing Address of Practice if Use on Claims is checked Physical Treating Address of Clinic Physical Treating Address of Practice	Pay To Address Phone of Practice Billing Address Phone of Practice if Use on Claims is checked Default Clinic Phone Default Practice Phone

Optional Patient ID

The Optional Patient ID entered on an Insurance Plan can be sent instead of a subscriber ID. To send the patient ID on e-claims, enable On e-claims use Optional Patient ID instead of Subscriber ID in Preferences. If no Optional Patient ID is added, Subscriber ID is used.

Prosthesis (Initial or Replacement)

E-claims: Claim-level information is not sent. Instead, information attached to individual procedures is sent. The claim-level field that is shown in the Claim  is ignored for e-claims. All e-claims are validated before they are sent. If the procedure-level prosthesis information is missing in the Procedure for any prosthesis procedure, the e-claim cannot be sent.

Paper claims: Only claim-level information is sent. Procedure-level prosthesis information is ignored when generating a paper claim.

Claim Note

Edit Claim window, Claim Note: On both e-claims and printed claims, the Attachment ID Number (Edit Claim - Attachments Tab) is included at the beginning of the note (e.g., if the Attachment ID Number is NEA#4521687 and the Claim Note is Patient is anemic, then the combined note is NEA#4521687 Patient is anemic) .

The Claim Note box is limited to 400 characters. On printed claims, the first 253 characters are printed. On e-claims, only the first 400 characters of the combined note are sent in the NTE segment of loop 2300.

Procedure Info window, E-claim Note: limited to 80 characters. This note is sent on e-claims in the SV3 segment of loop 2400. The 5010 format standards for this field have an 80-character limit restriction. Procedure e-claim notes are not included on printed claims.

CLM01

The specifications state,

The number that the submitter transmits in this position is echoed back to the submitter in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use completely unique numbers for this field for each individual claim.

Emdeon is known to add their own unique string to the end of whatever number is sent so that the number will be unique. In the case of a preauthorization followed by a claim, Denti-Cal requires that the number in this field be identical in both submissions. The string added by Emdeon would seem to break the requirement by Denti-Cal. Denti-Cal "has no funds" to refine their interfaces, so there may not be a workable solution.

DentalXChange replaces (but stores) the claim ID received on the claim with a unique claim ID since very few PMS programs supply unique numbers. You are able to search claims by either ID in ClaimConnect so that you will have the unique claim ID available if checking on a claim with a Payer.

Regardless of which clearinghouse is used, Open Dental does not submit an identical string in the claims as was submitted in the preauthorization. This behavior is consistent with the X-12 specifications, but does not follow the Denti-Cal requirements. It is a feature request to be able to send an identical CLM01 in both a preauth and subsequent claim.

Preauthorization DCN

This is only an issue with Denti-Cal. For other carriers, please see the discussion further down regarding the Original Reference Number in 2300 REF (F8).

Prior Authorization Number

Also called the Preauthorization Number.

In the X12 documentation, this is called 2300 REF (G1): Prior Authorization. This number can be sent from the Claim Edit window within the Prior Authorization dropdown inside of the Misc tab.

This field can be added to paper claims by adding PriorAuthString to the right of the PreAuthString field. When carriers want a preauthorization number, they are likely referring to this field.

Predetermination of Benefits Number

In the X12 documentation, this is called 2300 REF (G3): Predetermination Identification. This number can be sent from the Claim Edit window within the Predeterm Benefits box. On the paper Claim Form, we show this field as PreAuthString.

Quadrants

On paper claims, there is a column labeled 25. Area of Oral Cavity. In this column, there is a number (10, 20, 30, or 40) that corresponds to the quadrants (UR, UL, LL or LR).

For e-claims, the quadrant that was send can be verified from the raw text of the sent claim. To view raw claim data:

1. Go to the Account Module and open the claim.
2. Click History.
3. Look for the row(s) that start with SV3.
4. The quadrant will be noted in this row. For example, an SRP with code D4341, a fee of $175, performed in an office (11), with a quadrant of UL (20), and a quantity of 1, would look like this: SV3*AD:D4341*175*11*20**1~

Original Reference Number

In the X12 documentation, this is called 2300 REF (F8): Original Reference Number. In other places, it seems to be called one of the following:

• Original Document Control Number/Internal Control Number (DCN/ICN)
• Original Transaction Control Number (TCN)
• Claim Reference Number
• Payer Claim Control Number

This field is required by Medicaid when voiding a claim or replacing a claim by setting the CLM05-3. Users can enter the Original Reference Number in the Edit Claim - Misc Tab.

Attachment Control Number (ACN)

In the X12 documentation, this is placed in the Claim Supplemental Information loop, 2300 PWK06. To send an ACN in Open Dental, enter the number in the Attachment ID Number field in the Edit Claim - Attachments Tab. Only one ACN is allowed per claim.

There is a checkbox in Preferences for Require ACN# in remarks on claims with ADDP group name. This is an enforcement policy that includes ACN# in the remarks of the claim.

Medicaid of Iowa providers may now submit electronic claims relative to an approved Exception to Policy (ETP). Providers are instructed to enter the Exception to Policy number in the Attachment Control Number (ACN) field 2300 PWK06. When completing the ACN field the ETP number must be preceded with the letters ETP. Ex. ETP08-E1234.

Clinics and Providers

Providers should not move between clinics prior to version 11.1. In the Insurance Claims window, we encouraged but did not enforce sending claims for only one clinic at a time. A batch of claims goes to the clearinghouse as a single hierarchical file, grouped by billing provider. The billing address for a group of providers is pulled from the first claim in the group under the assumption that the provider/clinic relationship won't change in that group. This has been resolved in version 11.1 by enforcing batches to all belong to a single clinic.

Ordering Provider

Ordering Provider is only used in medical e-claims on a procedure level. The ordering provider in loop 2420E (one per procedure) is required for DMERC (Medicaid) carriers only and must be a person, not an organization, according to the X12 standard.

By default, the ordering provider is the treating provider, but this can be changed.

• An Ordering Provider Override can be set in the Edit Claim - Medical Tab or Edit Procedure - Medical Tab
• Provider override can be an internal or a referring provider.
• If an override is set on the procedure, it overrides providers set elsewhere.
• If no override is set, the preference for On e-claims, send treating provider info for each separate procedure determines the default ordering provider.
  • Enabled: The provider set on the procedure will be the ordering provider.
  • Disabled: The treating dentist set on the Edit Claim window will be the procedure's ordering provider.
• If an overriding ordering provider on a procedure is not a person (Not a Person checked on Provider), or has no last name, no ordering provider information will be sent with the claim.

Sites

If a Site is assigned to a procedure on a claim, and a default provider (not a person) and place of service (not office) are set for the site, the site NPI, place of service, and address will be sent in loop 2310C for new 5010 dental e-claims. This is the criteria that must be met:

• At least one procedure on the claim must have a site assigned.
• The site must have a default provider that is marked as Not a Person and has a valid NPI.
• The site must have a valid address, city, state, and zip code.
• The claim place of service is not Office.
• The site provider and claim billing provider cannot match.

Service Authorization Exception Code

Open Dental does not currently send or support this code. It is described in the X12 documentation as follows:

Used only in claims where providers are required by state law (e.g., New York State Medicaid) to obtain authorization for specific services but, for the reasons listed in REF02, performed the services without obtaining the service authorization. Check with your state Medicaid to see if this applies in your state.

Resubmission Codes

Resubmission codes are determined by the Correction Type in the Edit Claim - Misc Tab.

Original=1, Replacement=7, Void=8.

Gender

ADA only allows Male, Female, or Unknown as a gender on claims. If Other is selected as gender for a patient in Edit Patient Information, the gender will be sent as Unknown on the electronic claim.

Subscriber Date of Birth

For DentalXChange ClaimConnect, Vyne, Apex, or Electronic Dental Service (EDS), the subscriber date of birth is always sent.

For other clearinghouses, the subscriber date of birth is only transmitted when the subscriber is also the patient.

Coordination of Benefits

The Send Paid By Other Insurance At Preference requires Claim payment to be entered By Procedure in order to be included on subsequent claims (e.g., Secondary Insurance claims).

Rendering Provider Primary Identification

When using the 5010 format for DentalXChange ClaimConnect, ChangeHealthcare, Vyne, Tesia, or Electronic Dental Services (EDS), the provider's State License Number is always sent when using the default value for the GS03/ISA08 field.

Rendering Provider Secondary Identification

When using the 5010 format for DentalXChange ClaimConnect, ChangeHealthcare, Vyne, Tesia, or Electronic Dental Service (EDS), the provider's State License Number is always sent.