External Facility Code External Code Report the code the defines the location Type - Place of DC 31 11/8/12 Source Source 13 - char[2] code services were performed by the All 80% B Service Code 13 - Place of Service provider referenced on the claim Numeric Lookup Claim Claim Line Report the that defines the payment DC 32 11/8/12 - tlkpClaimStatus varchar[2] All 98% A0 Status Status status of this claim line Numeric Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied Processed as primary, forwarded to 19 additional Processed as secondary, forwarded to 20 additional payer(s) Processed as tertiary, forwarded to 21 additional payer(s) 22 Reversal of previous payment Not our claim, forwarded to additional 23 payer(s) 25 Predetermination Pricing Only - no payment External External Code Code CDT Source 10 - / CDT Report the Common Dental Terminology DC 33 11/8/12 Source char[5] All 99% A2 Code Current Dental Code code here 10 - Terminology Text External Report a valid Procedure modifier when a External Code Code HCPCS / CPT modifier clarifies / improves the reporting DC 34 11/8/12 Source 9 - char[2] All 0% C Modifier - Source Code Modifier accuracy of the associated procedure code Modifiers 1 9 - Text (DC032). External Report a valid Procedure modifier when a External Code Code HCPCS / CPT modifier clarifies / improves the reporting DC 35 11/8/12 Source 9 - char[2] All 0% C Modifier - Source Code Modifier accuracy of the associated procedure code Modifiers 2 9 - Text (DC032).
DC 31 Facility Type - 11/8/12 External Code Source 13 - Numeric External Code Source 13 - Place of Service char[2] Place of Service Code Report the code the defines the location code services were performed by the provider referenced on the claim All 80% B DC 32 Claim Status 11/8/12 Lookup - Numeric tlkpClaimStatus varchar[2] Claim Line Status Report the that defines the payment status of this claim line All 98% A0 Description 1 Processed as primary 2 Processed as secondary 3 Processed as tertiary 4 Denied 19 Processed as primary, forwarded to additional 20 Processed as secondary, forwarded to additional payer(s) 21 Processed as tertiary, forwarded to additional payer(s) 22 Reversal of previous payment 23 Not our claim, forwarded to additional payer(s) 25 Predetermination Pricing Only - no payment DC 33 CDT Code 11/8/12 External Code Source 10 - Text External Code Source 10 - Current Dental Terminology char[5] / CDT Code Report the Common Dental Terminology code here All 99% A2 DC 34 Modifier - 1 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (DC032). All 0% C DC 35 Modifier - 2 11/8/12 External Code Source 9 - Text External Code Source 9 - Modifiers char[2] HCPCS / CPT Code Modifier Report a valid Procedure modifier when a modifier clarifies / improves the reporting accuracy of the associated procedure code (DC032). All 0% C
v3-1-apcd-dental-claim-file-submission-guide-2013-06.docx