Dental Claim Billing Standard – J430 v4

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Contents

General

Purpose

Applicability

Basic Concepts

Detail

History

 

General

Purpose

The purpose of the Dental Billing Standard is to clearly describe the standard use of each field (Item Number) on the paper ADA Dental Claim Form and how to crosswalk the data to electronic Dental Claims (HIPAA 837, version 005010X224A1). The 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 Numbers indicate fields for specific information on the paper ADA Dental Claim Form; the purpose and use of each Item Number is derived from the ADA 2012 Dental claim form instructions. 

This document references a crosswalk from the paper ADA Dental Claim Form to the electronic Dental Claim (HIPAA 837, version 005010X224A1). Instead of Item Numbers, electronic claims have loops, segments, and elements (ex, 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 regarding the use of each ADA Item Number (box number) are given in the Dental Claim Form completion instructions:

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, which is available for purchase on http://store.x12.org/store/.
  2. To crosswalk between the paper ADA Dental Claim Form and the electronic dental claim format, reference the WEDI Dental White Paper[1].
  3. Providers are responsible for determining when the specific conditions and criteria apply to them.
  4. Error-checking (data edits) for electronic claims will follow the requirements outlined in the HIPAA Implementation Guide for dental claims (837 version 005010X224A1).
  5. Coordination of Benefits (COB) information should follow the CDT Standard and not be entered at the line level. Submitters may indicate the amount the primary carrier paid in the “Remarks” field (Item # 35).
  6. Claim forms must be typed (computer generated, typed, machine generated, etc.). Hand-written claim forms may be returned.

              

History

 

Original

V3.1

V3.2

ORIGINATION DATE

09/29/2009

04/04/2011

11/25/2013

APPROVAL DATE

12/02/2009

05/18/2011

01/09/2014

EFFECTIVE DATE

01/02/2010

06/18/2011

02/05/2014

 

 

V4

 

 

ORIGINATION DATE

6/12/2019

 

 

APPROVAL DATE

08/07/2019

 

 

EFFECTIVE DATE

09/07/2019

 

 

 

 

[1] https://www.wedi.org/forms/login/login?target=/knowledge-center/resource-view/resources/2018/07/02/dental-claims-white-paper

 

 

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