Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Appendix 590-243-F-2 - Maine Health Data Organization Dental Claims File Mapping to National Standards

Current through 2024-29, July 17, 2024
Data Element
								#
Data Element Name
ADA J400 Form
								Locator
HIPAA Reference ASC
								X12N/005010A1 Transaction Set/Loop/Segment ID/Code Value/Reference
								Designator
DC001
Submitter
N/A
N/A
DC002
Payor
N/A
N/A
DC003
Insurance Type/Product Code
N/A
835/2100/CLP/06
DC004
Payor Claim Control Number
N/A
835/2100/CLP/07
DC005
Line Counter
N/A
837/2400/LX/01
DC006
Insured Group or Policy Number
16
837/2000B/SBR/03
DC007
Subscriber Social Security Number
15
837/2010BA/REF/SY/02
DC008
Plan Specific Contract Number
N/A
835/2100/NM1/MI/08
DC009
Member Suffix or Sequence Number
N/A
N/A
DC010
Member Identification Code
N/A
835/2100/NM1/34/09
DC011
Individual Relationship Code
18
837/2000B/SBR/02, 837/2000C/PAT/01
DC012
Member Gender
22
837/2010BA/DMG/03, 837/2010CA/DMG/03
DC013
Member Date of Birth
21
837/2010BA/DMG/D8/02,
								837/2010CA/DMG/D8/02
DC014
Member City Name
20
837/2010BA/N4/01, 837/2010CA/N4/01
DC015
Member State or Province
20
837/2010BA/N4/02, 837/2010CA/N4/02
DC016
Member ZIP Code of Residence
20
837/2010BA/N4/03, 837/2010CA/N4/03
DC017
Date Service Approved
N/A
835/Header Financial Information/BPR/16
DC018
Rendering Provider Number
58
835/2100/REF/1A/02, 835/2100/REF/1B/02,
835/2100/REF/1C/02, 835/2100/REF/1D/02,
835/2100/REF/G2/02,
835/2100/NM1/BD/09, 835/2100/NM1/BS/09,
835/2100/NM1/MC/09, 835/2100/NM1/PC/09
DC019
Rendering Provider Tax ID Number
51
835/2100/NM1/FI/09
DC020
National Provider ID - Rendering
								Provider
54
837/2310B/NM1/XX/09
DC021
Rendering Provider Entity Type
								Qualifier
N/A
837/2310B/NM1/82/02
DC022
Rendering Provider First Name
N/A
837/2310B/NM1/82/04
DC023
Rendering Provider Middle Name
N/A
837/2310B/NM1/82/05
DC024
Rendering Provider Last Name or Organization
								Name
N/A
837/2310B/NM1/82/03
DC025
Rendering Provider Suffix
N/A
837/2310B/NM1/82/07
DC026
Rendering Provider Specialty
56A
837/2310B/PRV/PXC/03
DC027
Placeholder
N/A
N/A
DC028
Placeholder
N/A
N/A
DC029
Placeholder
N/A
N/A
DC030
Place of Service - Professional
38
837/2300/CLM/05-1
DC031
Claim Status
N/A
835/2100/CLP/02
DC032
CDT Code
29
837/2400/SV3/AD/01-2
DC033
Procedure Modifier - 1
N/A
837/2400/SV3/AD/01-3
DC034
Procedure Modifier - 2
N/A
837/2400/SV3/AD/01-4
DC035
Date of Service - From
24
837/2400/DTP/472/D8/03,
								837/2300/DTP/472/D8/03
DC036
Date of Service - Thru
24
837/2400/DTP/472/D8/03,
								837/2300/DTP/472/D8/03
DC037
Charge Amount
31
837/2400/SV3/02
DC038
Paid Amount
N/A
835/2110/SVC/03
DC039
Co-pay Amount
N/A
835/2110/CAS/PR/3-03
DC040
Coinsurance Amount
N/A
835/2110/CAS/PR/2-03
DC041
Deductible Amount
N/A
835/2110/CAS/PR/1-03
DC042
Billing Provider Number
52A
837/2010BB/REF/G2/02
DC043
National Provider ID - Billing
								Provider
49
837/2010AA/NM1/XX/09
DC044
Billing Provider Last Name
48
837/2010AA/NM1/ /03
DC045
Billing Provider Tax ID
51
837/2010AA/REF/EI/02
DC046
Billing Provider Address Line 1
48
837/2010AA/N3/01
DC047
Billing Provider Address Line 2
48
837/2010AA/N3/02
DC048
Billing Provider City Name
48
837/2010AA/N4/01
DC049
Billing Provider State or Province
48
837/2010AA/N4/02
DC050
Billing Provider Zip Code
48
837/2010AA/N4/03
DC051
Service Facility Location Name
N/A
837/2310C/NM1/77/2/03
DC052
National Provider ID - Service
								Facility
N/A
837/2310C/NM1/77/2/XX/09
DC053
Service Facility Location Address Line
								1
56
837/2310C/N3/01
DC054
Service Facility Location Address Line
								2
56
837/2310C/N3/02
DC055
Service Facility Location City Name
56
837/2310C/N4/01
DC056
Service Facility Location State or
								Province
56
837/2310C/N4/02
DC057
Service Facility Location Zip Code
56
837/2310C/N4/03
DC058
Service Facility Number
N/A
837/2310C/REF/G2/02
DC101
Subscriber Last Name
12
837/2010BA/NM1/ /03
DC102
Subscriber First Name
12
837/2010BA/NM1/ /04
DC103
Subscriber Middle Name
12
837/2010BA/NM1/ /05
DC104
Member Last Name
20
837/2010BA/NM1/ /03, 837/2010CA/NM1/
								/03
DC105
Member First Name
20
837/2010BA/NM1/ /04, 837/2010CA/NM1/
								/04
DC106
Member Middle Name
20
837/2010BA/NM1/ /05, 837/2010CA/NM1/
								/05
DC107
Member Address Line 1
20
837/2010BA/N3/01, 837/2010CA/N3/01
DC108
Member Address Line 2
20
837/2010BA/N3/02, 837/2010CA/N3/02
DC109
Member Country Code
837/2010BA/N4/04, 837/2010CA/N4/04
DC110
In-Plan Network Indicator
N/A
N/A
DC111
Placeholder
N/A
N/A
DC112
Oral Cavity 1
25
837/2400/SV304-01
DC113
Oral Cavity 2
25
837/2400/SV304-02
DC114
Oral Cavity 3
25
837/2400/SV304-03
DC115
Oral Cavity 4
25
837/2400/SV304-04
DC116
Oral Cavity 5
25
837/2400/SV304-05
DC117
Tooth Number or Letter (1)
27
837/2400/TOO/JP/02
DC118
Tooth - 1 Surface - 1
28
837/2400/TOO03-01
DC119
Tooth - 1 Surface - 2
28
837/2400/TOO03-02
DC120
Tooth - 1 Surface - 3
28
837/2400/TOO03-03
DC121
Tooth - 1 Surface - 4
28
837/2400/TOO03-04
DC122
Tooth - 1 Surface - 1
28
837/2400/TOO03-05
DC123
Tooth Number or Letter (2)
27
837/2400/TOO/JP/02
DC124
Tooth - 2 Surface - 1
28
837/2400/TOO03-01
DC125
Tooth - 2 Surface - 2
28
837/2400/TOO03-02
DC126
Tooth - 2 Surface - 3
28
837/2400/TOO03-03
DC127
Tooth - 2 Surface - 4
28
837/2400/TOO03-04
DC128
Tooth - 2 Surface - 5
28
837/2400/TOO03-05
DC129
Tooth Number or Letter (3)
27
837/2400/TOO/JP/02
DC130
Tooth - 3 Surface - 1
28
837/2400/TOO03-01
DC131
Tooth - 3 Surface - 2
28
837/2400/TOO03-02
DC132
Tooth - 3 Surface - 3
28
837/2400/TOO03-03
DC133
Tooth - 3 Surface - 4
28
837/2400/TOO03-04
DC134
Tooth - 3 Surface - 5
28
837/2400/TOO03-04
DC135
Tooth Number or Letter (4)
27
837/2400/TOO/JP/02
DC136
Tooth - 4 Surface - 1
28
837/2400/TOO03-01
DC137
Tooth - 4 Surface - 2
28
837/2400/TOO03-02
DC138
Tooth - 4 Surface - 3
28
837/2400/TOO03-03
DC139
Tooth - 4 Surface - 4
28
837/2400/TOO03-04
DC140
Tooth - 4 Surface - 5
28
837/2400/TOO03-05
DC899
Record Type
N/A
N/A