This blog post describes the mapping specifications and the conversion between HIPAA 837 dental and ADA (America Dental Association) J400 in PDF format.
This was one of the 300+ pre-defined HIPAA maps that Redix International, Inc. has developed in the past 20 years. The user can integrate this map into their system with no further work.
You can test the map by going to Redix HIPAA Compliance and Conversion Demo.
A blank ADA J400 form looks like the following.
Mapping Specification
The ADA J400 form is using the box id to identify the meaning of each field. For example, a patient name is in box 12 and the patient date of birth is in box 13. The patient name in a HIPAA 837 dental is defined in 2010BA. Below is a table to describe the box id in the ADA J400 form and its corresponding element in HIPAA 837 dental.
| Form Box ID | Mapping |
|---|---|
| 1 | Checkbox Xwalked from 2300 CLM12, 19 |
| 2 | 2300 REF02 (REF01="G1" | "G3") |
| 3 | 2010BB NM101, N3xx, N4xx |
| 4 | Checkbox Xwalked by existence of 2320 loop |
| 5 | 2330A NM103-05, 07 |
| 6 | Not Mapped |
| 7 | DNE in HIPAA 837 |
| 8 | 2330A NM109 |
| 9 | 2320 SBR03 |
| 10 | Checkbox Xwalked from 2320 SBR02 |
| 11 | 2330B NM103, N3xx, N4xx |
| 12 | 2010BA NM103-05,07, N3xx, N4xx |
| 13 | 2010BA DMG02, converted |
| 14 | Checkbox Xwalked From 2010BA DMG01 |
| 15 | 2010BA NM109 |
| 16 | 2000B SBR03 |
| 17 | 2000B SBR04 |
| 18 | Checkbox Xwalked From 2000B SBR02, overwritten by 2000C PAT01 |
| 19 | DNE in HIPAA 837 |
| 20 | Same as box 12 Unless Entire Set overwritten by 2010CA Equivalent |
| 21 | Same as box 13 Unless overwritten by 2000CA, converted |
| 22 | Checkbox Xwalked Same as box 14 unless overwritten by 2000CA |
| 23 | 2300 CLM01 |
| 24(1-10) | 2300 DTP03 (DTP01="472"), overwritten by 2400 DTP03 (DTP01="472"), converted |
| 25(1-10) | 2400 SV304:01 |
| 26(1-10) | 2400 TOO01 (first one only) |
| 27(1-10) | 2400 TOO02, concatenated |
| 28(1-10) | 2400 TOO03:01-05, concatenated |
| 29(1-10) | 2400 SV301:02 |
| 30(1-10) | 2400 SV301:07 |
| 31(1-10) | 2400 SV307 |
| 32 | DNE in HIPAA 837 |
| 33 | 2300 CLM02 |
| 34 | Multiple mappings. "X" Xwalked from 2300 DN201 |
| 35 | 2300 NTE02, concatentated |
| 36 | Xwalked from 2300 CLM09 |
| 37 | Xwalked from 2300 CLM08 |
| 38 | DNE in HIPAA 837 |
| 39 | Not Mapped |
| 40 | Checkbox Xwalked from 2300 DN101 |
| 41 | 2300 DTP03 (DTP01="452") |
| 42 | 2300 DN102 |
| 43 | Checkbox Xwalked from 2400 SV305 |
| 44 | 2400 DTP03 (DTP01="441"), converted |
| 45 | Xwalked from 2300 CLM11:01-02 |
| 46 | 2300 DTP03 (DTP01="439") |
| 47 | 2300 CLM11:04 |
| 48 | 2010AA NM103-05,07, N3xx, N4xx |
| 49 | 2010AA NM109 (NM108="XX") |
| 50 | 2300 REF02 (REF01="0B") |
| 51 | 2300 REF02 (REF01="EI" | "SY") |
| 52 | 1000A PER03 | 05 | 07 (qual="TE") |
| 52A | 2300 REF02 (last one, not "0B", "EI", "SY") |
| 53 | Xwalked from 2300 CLM06 |
| 54 | Same as box 49, unless overwritten by 2310B equivalent |
| 55 | Same as box 50, unless overwritten by 2310B equivalent |
| 56 | 2010AA N3xx, N4xx |
| 56a | 2010AA PRV03, overwritten by 2310B PRV03 |
| 57 | Same as box 52 |
| 58 | Not Mapped |
Some of the notes about this conversion:
- Validates the input file. Only the file 837 is validated, the file will be converted.
- Generates PDF file for each claim.
Example
Below is an 837 dental example:
ISA*00* *00* *ZZ*123456789012345*ZZ*123456789012345*030101*1253*^*00501*987654321*1*T*: GS*HC*123456789012345*123456789012345*19991231*0802*123456789*X*005010X224A2 ST*837*0322*005010X224A2 BHT*0019*00*0123*20061123*1023*CH NM1*41*1*41-LAST*41-FIRST*41-MIDDLE***46*41-46-PRIMARY PER*IC*41-CONTACT*TE*41-TE*FX*41-FX*EM*41-EM PER*IC*41-CONTACT*TE*41-TE*FX*41-FX*EM*41-EM NM1*40*2*40-NAME*****46*40-46-PRIMARY HL*1**20*1 PRV*BI*PXC*2000A-TAXONOMY CUR*85*CAD NM1*85*1*85-LAST*85-FIRST*85-MIDDLE***XX*1234567893 N3*85-ADDRESSLINE1*85-ADDRESSLINE2 N4*85-CITY*FL*33411 REF*EI*123456789 REF*1G*85-1G-SECONDARY REF*0B*85-0B-SECONDARY PER*IC*85-CONTACT*TE*85-TE*FX*85-FX*EM*85-EM PER*IC*85-CONTACT*TE*85-TE*FX*85-FX*EM*85-EM NM1*87*1 N3*87-ADDRESSLINE1*87-ADDRESSLINE2 N4*87-CITY*FL*33411 NM1*PE*2*PE-NAME*****PI*PE-PI-PRIMARY N3*PE-ADDRESSLINE1*PE-ADDRESSLINE2 N4*PE-CITY*FL*33411 REF*2U*PE-2U-SECONDARY REF*EI*123456789 HL*2*1*22*1 SBR*S********CI NM1*IL*1*ENERST*WILLIAM***SUF*MI*IL-MI-PRIMARY DMG*D8*19751221*M NM1*PR*2*PLAN ABC*****PI*PR-PI-PRIMARY N3*PR-ADDRESSLINE1*PR-ADDRESSLINE2 N4*PR-CITY*MO*64015 HL*3*2*23*0 PAT*19 NM1*QC*1*GAGA*SINGER***SUF N3*123 APPLEWOOD LN N4*GARDEN CITY*MO*64015 DMG*D8*19751221*M REF*Y4*QC-Y4-SECONDARY CLM*SMITH788*4000***11:B:1*Y*C*Y*I DTP*439*D8*20060108 DTP*452*D8*20060108 DTP*472*D8*20060108 DTP*050*D8*20051030 DN1*36*27 DN2*8*E****JP PWK*OZ*BM***AC*DMN0012 CN1*02*550 AMT*F5*152.45 REF*G3*13579 REF*4N*1 REF*F8*R555588 REF*9F*12345 REF*G1*13579 REF*9A*RJ55555 REF*9C*RP44444444 REF*D9*TJ98UU321 K3*STATE DATA REQUIREMENT NTE*ADD*PATIENT IS EXTREMELY SENSITIVE TO PAIN AND REQUIRES ADDITIONAL SEDATION HI*BK:52403*BF:52404 HCP*03*100*10*RPO12345 NM1*DN*1*SMITH*JO0HN***SUF*XX*1234567893 PRV*RF*PXC*DN-TAXONOMY REF*0B*DN-0B-SECONDARY REF*1G*DN-1G-SECONDARY REF*G2*DN-G2-SECONDARY SBR*P*01*GR00786******13 CAS*OA*93*15.06 AMT*D*411 AMT*EAF*75 AMT*A8*273 OI***Y***I MOA***A4 NM1*IL*1*JORDAN*DALE*E**SUF*MI*IL-MI-PRIMARY N3*IL-ADDRESSLINE1*IL-ADDRESSLINE2 N4*IL-CITY*MO*64015 NM1*PR*2*HEALTH PLAN A*****PI*PR-PI-PRIMARY DTP*573*D8*20040203 LX*1 SV3*AD:D8080*4000****1 TOO*JP*12*L:O DTP*472*D8*20060108 DTP*441*D8*19980401 DTP*452*D8*20040927 DTP*446*D8*20041027 DTP*196*D8*20041015 DTP*198*D8*20041029 CN1*02*550 REF*6R*54321 REF*9A*RJ55555 REF*9C*RP44444444 AMT*T*45 HCP*03*100*10*RPO12345 SE*94*0322 GE*1*123456789 IEA*1*987654321
The generated PDF file is as follows.
About Us
Redix International, Inc. is an enterprise software company. Redix develops software and provides services to help organizations convert their proprietary or organization-specific data to standardized data. Among the standardized formats supported are X12, EDIFACT, XML, NSF, UB92, HIPAA, HL7, CDA, Blue-Ribbon, FHIR, NCPDP, and PDF.
