N.H. Code Admin. R. Ins 4010.04
(b) Dental Claims File Header Record Layout
Table 4010.04 (b) Dental Claims Header File Record Layout
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
HD001
Record Type
Text
2
HD
HD002
Payer
Text
8
Payer submitting payments. NHID Submitter Code
HD003
National Plan ID
Text
30
CMS National Plan ID
HD004
Type of File
Text
2
DC Dental Claims
HD005
Period Beginning Date
Date
8
Beginning of paid period for claims or beginning of month covered for eligibility
HD006
Period Ending Date
Date
8
End of paid period for claims or end of month covered for eligibility
HD007
Comments
Text
80
Submitter may use to document this submission by assigning a filename, system source, etc.
(c) Dental Claims File Trailer Record Layout
Table 4010.04 (c) Dental Claims Trailer File Record Layout
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
TR001
Record Type
Text
2
TR
TR002
Payer
Text
8
Payer submitting payments. NHID Submitter Code
TR003
National Plan ID
Text
30
CMS National Plan ID
TR004
Type of File
Text
2
DC Dental Claims
TR005
Period Beginning Date
Date
8
Beginning of paid period for claims or beginning of month covered for eligibility
TR006
Period Ending Date
Date
8
End of paid period for claims or beginning of month covered for eligibility
TR007
Extraction Date
Date
8
Date file was created
TR008
Record Count
Number
10 (0)
Total number of records submitted in this file
(d) Dental Claims Detailed File Specifications
Table 4010.04 (d) Dental Claims Detailed File Specifications
Data Element #
Element
Type
Length (decimal places)
Description/Codes/Sources
DC001
Payer
Text
8
Payer submitting payments
DC002
National Plan ID
Text
30
CMS National Plan ID
DC003
Insurance Type/Product Code
Text
2
As established by X12 Accredited Standards Committee, available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133161000
DC004
Payer Claim Control Number
Text
35
Must apply to entire claim and be unique within payer's system
DC005
Line Counter
Text
4
Line number for this service. The line counter begins with 1 and is incremented by 1 for each additional service line of a claim
DC006
Insured Group or Policy Number
Text
50
Group or policy number (not the number that uniquely identifies the subscriber)
DC007
Subscriber Social Security Number
Text
9
Subscriber's social security number. Do not include dashes. Leave blank if not available.
DC008
Plan Specific Contract Number
Text
50
Plan assigned contract number. Leave blank if Plan Specific Contract Number is subscriber’s social security number.
If this is a Medicaid claim, provide Medicaid ID.
DC009
Member Suffix or Sequence Number
Text
20
Uniquely identifies the member within the contract
DC010
Member Social Security Number
Text
9
Member’s social security number. Do not include dashes. Leave blank if not available.
DC011
Individual Relationship Code
Text
2
See Table 4010.6 (b) Relationship Codes
DC012
Member Gender
Text
1
M Male
F Female
U Unknown
O Other
DC013
Member Date of Birth
Date
8
DC014
Member City Name
Text
30
City name of member
DC015
Member State or Province
Text
2
As defined by the U.S. Postal Service
DC016
Member ZIP Code
Text
9
ZIP Code of member – may include non- US codes. Do not include dash.
DC017
Paid Date/AP Date
Date
8
DC018
Service Provider Number
Text
30
Payer assigned provider number
DC019
Service Provider Tax ID Number
Text
10
Federal taxpayer's identification number – if the tax id is a provider’s social security number use ‘SSN’ and ‘NA’ if unavailable
DC020
National Service Provider ID
Text
20
Required if National Provider ID is mandated for use under HIPAA
DC021
Service Provider Entity Type Qualifier
Text
1
HIPAA provider taxonomy classifies provider groups (clinicians who bill as a group practice or under a corporate name, even if that group is composed of one provider) as “Person”.
1 Person
2 Non-Person Entity
DC022
Service Provider First Name
Text
35
Individual first name. Leave blank if provider is a facility or organization
DC023
Service Provider Middle Name
Text
25
Individual middle name or initial. Leave blank if provider is a facility or organization
DC024
Servicing Provider Last Name or Organization Name
Text
60
Report the name of the organization or last name of the individual provider. DC021 determines if this is an Organization or Individual Name reported here.
DC025
Service Provider Suffix
Text
10
Suffix to individual name. Leave blank if provider is a facility or organization
DC026
Service Provider Specialty
Text
10
National Uniform Claims Committee (NUCC) standard code that defines this provider for this line of service. Dictionary for specialty code values must be supplied during testing.
DC027
Service Provider City Name
Text
30
City name of provider - practice location
DC028
Service Provider State or Province
Text
2
As defined by the U.S. Postal Service
DC029
Service Provider ZIP Code
Text
9
ZIP Code of provider - may include non-US codes.
DC030
Place of Service - Professional
Text
2
See Table 4010.6 (g) Place of Service -- Professional
DC031
Claim Status
Text
2
See Table 4010.6 (h) Claim Status
DC032
CDT Code
Text
5
Common Dental Terminology code
DC033
Procedure Modifier - 1
Text
2
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
DC034
Procedure Modifier - 2
Text
2
Procedure modifier required when a modifier clarifies/improves the reporting accuracy of the associated procedure code
DC035
Date of Service - From
Date
8
First date of service for this service line.
DC036
Date of Service - Thru
Date
8
Last date of service for this service line.
DC037
Charge Amount
Number
10 (2)
The full, undiscounted total and service-specific charges billed by the provider.
DC038
Paid Amount
Number
10 (2)
Includes any withhold amounts.
DC039
Copay Amount
Number
10 (2)
The present, fixed dollar amount for which the individual is responsible.
DC040
Coinsurance Amount
Number
10 (2)
The dollar amount an individual is responsible for - not the percentage.
DC041
Deductible Amount
Number
10 (2)
Deductible amount in dollars
DC042
Billing Provider Number
Text
30
Carriers, third-party administrators, and dental claims processors shall code using the payer assigned billing provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change
DC043
National Billing Provider Number ID
Text
30
This is the NPI for the billing provider
DC044
Billing Provider Last Name
Text
60
Full name of provider billing organization or last name of individual billing provider.
DC101
Subscriber Last Name
Text
60
DC102
Subscriber First Name
Text
35
DC103
Subscriber Middle Initial
Text
1
DC104
Member Last Name
Text
60
DC105
Member First Name
Text
35
DC106
Member Middle Initial
Text
1
DC201
Carrier Associated with Claim
Text
8
For each claim, the NAIC code of the carrier when a TPA processes claims on behalf of the carrier. Optional if all dental claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.
DC202
Carrier Plan Specific Contract Number or Subscriber/Member Social Security Number
Text
128
For each claim, the carrier specific contract number or subscriber/member social security number when a TPA processes claims on behalf of the carrier. Optional if all medical claims processed by a TPA under contract to a carrier for carved-out services are submitted by the carrier with unified member IDs in all files.
DC203
Practitioner Group Practice
Text
60
Name of group practice to which a practitioner is affiliated if different from DC044.
DC204
Tooth Number/Letter
Text
2
Report the tooth identifier(s) when DC032 is within the given range. Required when DC032 = D2000 thru D2999
DC205
Dental Quadrant
Text
2
Standard quadrant identifier from the External Code Source referenced in Ins 4009.05. Provides further detail on procedure(s)
DC206
Tooth Surface
Text
5
Tooth surface(s) that this service relates to. Provides further detail on procedure
DC207
Claim Version
Text
4
Version number of this claim service line. The version number begins with 0 and is incremented by 1 for each subsequent version of that service line. No alpha or special characters.
DC208
Diagnosis Code
Text
7
ICD CM Diagnosis Code when applicable
DC209
ICD Indicator
Text
1
Report the value that defines whether the diagnoses on claim are ICD9 or ICD10.
0 ICD-9
1 ICD-10
DC211
Cross Reference Claims ID
Text
35
The original Payer Claim Control Number (DC004). Used when a new Payer Claim Control Number is assigned to an adjusted claim.
DC212
Allowed amount
Number
10 (0)
Report the maximum amount contractually allowed and that a carrier will pay to a provider for a particular procedure or service. This will vary by provider contract and most often it is less than or equal to the fee charged by the provider. Shall be reported even when paid amount = 0 but member receives care. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070
DC213
HIOS Plan ID
Text
16
The 16 character HIOS Plan ID (Standard component). Including a five digit issuer ID, two character state ID, three digit product number, four digit standard component number and two digit variant component ID. This field may not be available for all market segments; Leave blank where not available
DC215
Service Line Type
Text
1
Report the code that defines the claim line status in terms of adjudication
O Original
V Void
R Replacement
B Back Out
A Amendment
DC218
Claim Processing Level Indicator
Text
1
1 Claim Level
2 Service Line level
DC219
Denied Claim Indicator
Text
1
1 Fully Paid – the entire claim was paid at the allowed amount
2 Partially denied – some of the claims lines were paid at the allowed amount
3 Encounter claim – this claim records a service provided that is paid under a non FFS payment arrangement such as capitation
4 No payment – no payment made for reasons other than non FFS payment arrangement
DC220
Denial Reason
Text
4
Denial reason code. Required when denied claim indicator = 2 or 4 http://www.wpc-edi.com/reference/
DC899
Record Type
Text
2
DC
DC900
In Network Indicator
Text
1
A yes/no indicator that specifies that the provider (not the benefit) is within the health plan network. Valid codes: Y=Yes, N=No
DC901
Quantity
Number
12(0)
Count of services performed
Source. #10877, eff 7-10-15; ss by #13136, eff 11-24-20