Dental Claims JSON

Submit an 837D dental claim in JSON format

POST /dental-claims/submission

This endpoint sends 837D dental claims to payers.

1. Call this endpoint with a JSON payload.
2. Stedi translates your request to the X12 837 EDI format and sends it to the payer.
3. The endpoint returns a response from Stedi in JSON format containing information about the claim you submitted and whether the submission was successful.

Visit Submit dental claims for a full how-to guide.

Authorizations

Authorization · Required Header

A Stedi API Key for authentication.

Body

application/json

assistantSurgeon · Object

Information about the assistant surgeon who rendered the care. Use this object when the rendering providers provided these services in the role of the assistant surgeon.

This should be an individual, not an organization, and you should supply at least the surgeon's lastName, taxonomyCode, and an identifier, which is typically the npi.

address · assistantSurgeon.address · Object

address1 · assistantSurgeon.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · assistantSurgeon.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · assistantSurgeon.address.city · String Required

The city name.

countryCode · assistantSurgeon.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · assistantSurgeon.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · assistantSurgeon.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · assistantSurgeon.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

commercialNumber · assistantSurgeon.commercialNumber · String

The provider's commercial number.

contactInformation · assistantSurgeon.contactInformation · Object

You must include at least one communication method (phone, fax, or email) in this object.

email · assistantSurgeon.contactInformation.email · String

The email address.

faxNumber · assistantSurgeon.contactInformation.faxNumber · String

The fax number.

name · assistantSurgeon.contactInformation.name · String

The full name of the person or office.

phoneExtension · assistantSurgeon.contactInformation.phoneExtension · String

The phone extension, if applicable.

phoneNumber · assistantSurgeon.contactInformation.phoneNumber · String

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.

firstName · assistantSurgeon.firstName · String

The assistant surgeon's first name.

lastName · assistantSurgeon.lastName · String Required

The assistant surgeon's last name. You must include either the lastName or organizationName property in this object.

locationNumber · assistantSurgeon.locationNumber · String

The provider's location number.

middleName · assistantSurgeon.middleName · String

The assistant surgeon's middle name or initial.

npi · assistantSurgeon.npi · String Regex pattern: ^\d{10}$

The individual National Provider Identifier (NPI) assigned to the surgeon.

providerUpinNumber · assistantSurgeon.providerUpinNumber · String Deprecated

Deprecated; do not use.

stateLicenseNumber · assistantSurgeon.stateLicenseNumber · String

The provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · assistantSurgeon.suffix · String

The assistant surgeon's name suffix, such as Jr. or III.

taxonomyCode · assistantSurgeon.taxonomyCode · String Required Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty. For example, code 1223S0112X is for Oral and Maxillofacial Surgery.

billing · Object Required

Information about the billing provider.

• For tax identification, you must include either the provider's Social Security Number (SSN) in the ssn property or their Employer Identification Number (EIN) in the employerId property, but not both.
• If the billing provider has an NPI, you must include it in the npi property. If the billing provider does not have an NPI, you must include either the commercialNumber or the locationNumber for identification. Some payers may require the npi and either the commercialNumber or the locationNumber as a secondary identifier.
• Some solo providers may use their SSN as their EIN. In this case, submit the SSN in the ssn property and leave the employerId property blank.

address · billing.address · Object

The billing provider's address. This must be a physical practice location where care is delivered. If the billing provider receives mail at a PO Box, lockbox, or other non-physical address, you can provide that address in the payToAddress object.

For United States addresses, you must include the full nine-digit zip code with no separators, such as 100031502. If you don't know the full zip code, you can find it using the USPS ZIP Code Lookup tool.

address1 · billing.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · billing.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · billing.address.city · String Required

The city name.

countryCode · billing.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · billing.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · billing.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · billing.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

commercialNumber · billing.commercialNumber · String

The billing provider's commercial number, as assigned by this payer. The commercial number is a unique identifier that the payer assigns to the provider. For providers without an NPI, you must provide either the commercialNumber or the locationNumber for identification.

contactInformation · billing.contactInformation · Object

Contact information for the billing provider. You can include a maximum of two objects in this array.

email · billing.contactInformation.email · String

The email address.

faxNumber · billing.contactInformation.faxNumber · String

The fax number.

name · billing.contactInformation.name · String

The full name of the person or office.

phoneExtension · billing.contactInformation.phoneExtension · String

The phone extension, if applicable.

phoneNumber · billing.contactInformation.phoneNumber · String

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.

employerId · billing.employerId · String

The billing provider's Employer Identification Number (EIN). Typically a string of exactly nine numbers with no separators, unless otherwise instructed by the payer. If you include this value, you cannot include the ssn.

firstName · billing.firstName · String

The billing provider's first name, if the provider is an individual.

lastName · billing.lastName · String

The provider's last name, if the provider is an individual.

locationNumber · billing.locationNumber · String

The billing provider's location number. For providers without an NPI, you must provide either the commercialNumber or the locationNumber for identification.

middleName · billing.middleName · String

The provider's middle name or initial, if the provider is an individual.

npi · billing.npi · String Regex pattern: ^\d{10}$

The billing provider's National Provider Identifier (NPI).

organizationName · billing.organizationName · String

The provider's business name.

providerType · billing.providerType · String Deprecated

This field is now automatically populated and it only remains for backwards compatibility.

providerUpinNumber · billing.providerUpinNumber · String Deprecated

Deprecated; do not use.

ssn · billing.ssn · String Regex pattern: ^\d{9}$

The billing provider's Social Security Number. Must be a string of exactly nine numbers with no separators. If you include this value, you cannot include the employerId.

stateLicenseNumber · billing.stateLicenseNumber · String

The billing provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · billing.suffix · String

The provider's name suffix, such as Jr. or III.

taxonomyCode · billing.taxonomyCode · String Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the billing provider's type and/or area of specialty.

claimIdentifier · String

A code specifying the type of transaction. Defaults to CH if not provided.

• 31: Only for use by state Medicaid agencies performing post payment recovery.
• CH: Use when the transaction contains only fee for service claims or claims with at least one chargeable line item. Also use when it's not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters.
• RP: Use for capitated encounters. Also use when the transaction is being sent to an entity for purposes other than adjudication of a claim. For example, when you're sending the claim to a state health agency that is using the claim for health data reporting purposes.

Possible values

31

CH

RP

claimInformation · Object Required

Information about the healthcare claim.

Note that the objects and properties marked as required are required for all claims, while others are conditionally required, depending on type of claim and claim circumstances. For example, you must always provide the placeOfServiceCode property, but you only need to provide the otherSubscriberInformation object in coordination of benefits scenarios. When you include a conditionally required object, you must provide all of its required properties.

autoAccidentCountryCode · claimInformation.autoAccidentCountryCode · String

The country code where the accident occurred. Use when relatedCausesCode = AA and the accident occurred in a country other than US or Canada.

autoAccidentStateCode · claimInformation.autoAccidentStateCode · String

A code identifying the state or province in which the automobile accident occurred. Use this code when relatedCausesCode is set to AA.

benefitsAssignmentCertificationIndicator · claimInformation.benefitsAssignmentCertificationIndicator · String Required

A code indicating whether the patient or an authorized person has authorized the plan to remit payment directly to the provider. Use W when the patient refuses to assign benefits. Can be set to N - No (Payment should go to the patient), Y - Yes (Payment should go directly to the provider), or W - Not Applicable (use when patient refuses to assign benefits).

Possible values

N

W

Y

claimChargeAmount · claimInformation.claimChargeAmount · String Required Regex pattern: ^\d+(\.\d{1,2})?$

The total dollar amount charged for the services on this claim, expressed as a decimal. For example, 100.50. This is the total amount before any adjustments or payments. The amount must balance to the sum of the service line charges.

claimContractInformation · claimInformation.claimContractInformation · Object

Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.

contractAmount · claimInformation.claimContractInformation.contractAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The total dollar amount of the contract, expressed as a decimal. For example, 100.50.

contractCode · claimInformation.claimContractInformation.contractCode · String

The contract code. This is a unique identifier for the contract.

contractPercentage · claimInformation.claimContractInformation.contractPercentage · String

The allowance or charge percent, expressed as a decimal. For example, 0.80.

contractTypeCode · claimInformation.claimContractInformation.contractTypeCode · String Required

A code identifying the type of contract. Can be set to 02 - Per Diem, 03 - Variable Per Diem, 04 - Flat, 05 - Capitated, 06 - Percent, or 09 - Other.

Possible values

02

03

04

05

06

contractVersionIdentifier · claimInformation.claimContractInformation.contractVersionIdentifier · String

An additional identifer for the contract. Identifies the revision level of a particular format, program, technique or algorithm.

termsDiscountPercentage · claimInformation.claimContractInformation.termsDiscountPercentage · String

Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date.

claimDateInformation · claimInformation.claimDateInformation · Object

Dates related to services within the claim, including the date an appliance was placed and the date of the accident (if applicable). All dates apply to all services in the claim unless specifically overridden within an individual service line.

accidentDate · claimInformation.claimDateInformation.accidentDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date of the accident related to this claim. Required when relatedCausesCode is set to AA - Auto Accident or OA - Other Accident. Also required when relatedCausesCode is set to EM - Employment and this claim is the result of an accident.

appliancePlacementDate · claimInformation.claimDateInformation.appliancePlacementDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the appliance was placed.

repricerReceivedDate · claimInformation.claimDateInformation.repricerReceivedDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the repricing entity received the initial claim. Required when a repricer is passing the claim onto the payer.

serviceDate · claimInformation.claimDateInformation.serviceDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])(-\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01]))?$

A single service date or a range of service dates.

claimFilingCode · claimInformation.claimFilingCode · String

A code identifying the type of claim. For example DS - Disability.

• Use OF when submitting Medicare Part D claims.
• Use ZZ when you don't know the type of insurance.
• Some payers reject claims with invalid codes. If you're not sure which code to use, we recommend running a real-time eligibility check and using the value returned in the most relevant benefitsInformation.insuranceTypeCode property. Note that the eligibility response uses a different code list than claims, so you may need to map that code value to the appropriate claim filing code.

Visit Claims code lists for a complete list.

Possible values

11

12

13

14

15

claimFrequencyCode · claimInformation.claimFrequencyCode · String Required

Bill Type Frequency Code specifying the frequency of the claim. Can be set to 1 - Admit thru Discharge Claim, 7 - Replacement of Prior Claim, or 8 - Void/Cancel of Prior Claim.

• Set this to 1 when you're submitting a new claim and when you're resubmitting a claim that was rejected before it entered the payer's processing system. You must also set this property to 1 for every resubmission to Original Medicare because Original Medicare doesn't accept code 7.
• Set this to 7 when you need to resubmit a corrected claim that the payer has already processed. These are claims that the payer has already adjudicated or claims that the payer has rejected with a 277CA containing the Payer Claim Control Number (PCCN), indicating it has entered the payer's system.
• When resubmitting with code 7 or voiding with code 8, you must also include the Payer Claim Control Number (sometimes called the ICN) in the claimInformation.claimSupplementalInformation.claimControlNumber property. An exception is Original Medicare, which requires that you omit the Payer Claim Control Number from resubmissions.
• For resubmissions and cancellations, we strongly recommend including a unique Patient Control Number in the claimInformation.patientControlNumber for tracking purposes.

Visit Resubmit or cancel claims for complete details.

Possible values

1

7

8

claimNotes · claimInformation.claimNotes · Array of Strings Items: 1 - 5

Include comments or special instructions related to the claim. Required when the provider needs to include additional information to substantiate the medical treatment that can't be provided elsewhere in the claim submission. You can include up to five objects in this array.

claimPricingRepricingInformation · claimInformation.claimPricingRepricingInformation · Object

Repricing information to be completed by repricers, not providers. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

exceptionCode · claimInformation.claimPricingRepricingInformation.exceptionCode · String

Code specifying the exception reason for consideration of out-of-network health care services. This is the reason generated by the third-party health organization. Visit Claims code lists for a complete list.

Possible values

1

2

3

4

5

policyComplianceCode · claimInformation.claimPricingRepricingInformation.policyComplianceCode · String

Code indicating the policy compliance. Visit Claims code lists for a complete list.

Possible values

1

2

3

4

5

pricingMethodologyCode · claimInformation.claimPricingRepricingInformation.pricingMethodologyCode · String Required

Code indicating the pricing or repricing methodology. Visit Claims code lists for a complete list.

Possible values

00

01

02

03

04

rejectReasonCode · claimInformation.claimPricingRepricingInformation.rejectReasonCode · String

Code indicating the rejection message returned from the third party organization. Visit Claims code lists for a complete list.

Possible values

T1

T2

T3

T4

T5

repricedAllowedAmount · claimInformation.claimPricingRepricingInformation.repricedAllowedAmount · String Required Regex pattern: ^\d+(\.\d{1,2})?$

The dollar amount, expressed as a decimal. For example, 100.50.

repricedApprovedAmbulatoryPatientGroupAmount · claimInformation.claimPricingRepricingInformation.repricedApprovedAmbulatoryPatientGroupAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The dollar amount, expressed as a decimal.

repricedApprovedAmbulatoryPatientGroupCode · claimInformation.claimPricingRepricingInformation.repricedApprovedAmbulatoryPatientGroupCode · String

The code indicating the type of repricing.

repricedSavingAmount · claimInformation.claimPricingRepricingInformation.repricedSavingAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The dollar amount, expressed as a decimal.

repricingOrganizationIdentifier · claimInformation.claimPricingRepricingInformation.repricingOrganizationIdentifier · String

The identifier of the organization that repriced the claim.

repricingPerDiemOrFlatRateAmount · claimInformation.claimPricingRepricingInformation.repricingPerDiemOrFlatRateAmount · String

The pricing rate associated with per diem or flat rate repricing, expressed as a decimal.

claimSupplementalInformation · claimInformation.claimSupplementalInformation · Object

Additional information or documentation required for the claim. This is where you can include information about attachments, if applicable.

adjustedRepricedClaimNumber · claimInformation.claimSupplementalInformation.adjustedRepricedClaimNumber · String

Required when the repricer believes this information is necessary. Providers should not complete this property.

claimControlNumber · claimInformation.claimSupplementalInformation.claimControlNumber · String

This is the Payer Claim Control Number (PCCN) for an existing claim that this claim is meant to replace or cancel. This property is generally required when the claimInformation.claimFrequencyCode is set to 7 or 8. One exception to this guidance is Original Medicare, which specifies that you omit the PCCN from resubmissions.

Visit Resubmit or cancel claims for complete details and information about where to find the PCCN for an existing claim.

claimNumber · claimInformation.claimSupplementalInformation.claimNumber · String Deprecated

The claim number assigned by clearinghouse, van, etc.

Stedi overwrites this value when it sends the claim to the payer, so you shouldn't include this property in your request. We strongly recommend using the claimInformation.patientControlNumber property as your claim tracking ID.

predeterminationOfBenefitsIdentifier · claimInformation.claimSupplementalInformation.predeterminationOfBenefitsIdentifier · String

The Predetermination of Benefits Identification Number assigned by the payer. Required for services that have been previously predetermined and are now being submitted for payment. The identifier you supply here applies to the entire claim.

priorAuthorizationNumber · claimInformation.claimSupplementalInformation.priorAuthorizationNumber · String

Required when an authorization number is assigned by the payer or UMO and the services on this claim were preauthorized. This authorization number applies to the payer you listed in the receiver object. If you need to include authorization numbers for other payers, you can include them in claimInformation.otherSubscriberInformation.otherPayerName.otherPayerPriorAuthorizationNumber.

Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information.

referralNumber · claimInformation.claimSupplementalInformation.referralNumber · String

Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) and a referral is involved.

reportInformation · claimInformation.claimSupplementalInformation.reportInformation · Object

Required when you plan to submit an attachment for the claim electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request.

Use this object when there is a single attachment for the claim. If there are multiple attachments, use the reportInformations array instead.

attachmentControlNumber · claimInformation.claimSupplementalInformation.reportInformation.attachmentControlNumber · String

A control number assigned to the attachment. The payer uses this identifier to match the attachment to the claim.

• You must include either this property or attachmentId in the request, but not both. Including both properties will result in an error.
• We recommend using a ULID or UUID of up to 50 characters.
• Stedi autogenerates a control number if you don't provide one.

attachmentId · claimInformation.claimSupplementalInformation.reportInformation.attachmentId · String Regex pattern: ^[0-9a-f]{8}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{12}$ Length: 36

The unique identifier for the attachment file you previously uploaded to Stedi. This value is returned in the attachmentId property of the Create Claim Attachment (275) JSON response. Stedi uses it to generate and submit the 275 claim attachment transaction to the payer.

• This property is required when you're submitting attachment files through Stedi.
• You must include either this property or attachmentControlNumber in the request, but not both. Including both properties will result in an error.

attachmentReportTypeCode · claimInformation.claimSupplementalInformation.reportInformation.attachmentReportTypeCode · String Required

Code indicating the title or contents of a document, report or supporting item. For example, B4 - Referral Form or DA - Dental Models. Visit Claims code lists for a complete list.

Possible values

B4

DA

DG

EB

OZ

attachmentTransmissionCode · claimInformation.claimSupplementalInformation.reportInformation.attachmentTransmissionCode · String Required

Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.

Set this to EL when you plan to submit attachments electronically through Stedi APIs.

Possible values

AA

BM

EL

EM

FT

reportInformations · claimInformation.claimSupplementalInformation.reportInformations · Array of Objects Items: 0 - 10

An array of report information for the claim. Use this when you need to submit multiple report information records. You can submit up to 10 objects in this array.

Required when you plan to submit attachments for the claim electronically through Stedi APIs or SFTP, when there is a paper attachment following this claim, or when the provider deems it necessary to identify that they have additional information at their office that is available upon request.

attachmentControlNumber · claimInformation.claimSupplementalInformation.reportInformations[].attachmentControlNumber · String

A control number assigned to the attachment. The payer uses this identifier to match the attachment to the claim.

• You must include either this property or attachmentId in the request, but not both. Including both properties will result in an error.
• We recommend using a ULID or UUID of up to 50 characters.
• Stedi autogenerates a control number if you don't provide one.

attachmentId · claimInformation.claimSupplementalInformation.reportInformations[].attachmentId · String Regex pattern: ^[0-9a-f]{8}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{12}$ Length: 36

The unique identifier for the attachment file you previously uploaded to Stedi. This value is returned in the attachmentId property of the Create Claim Attachment (275) JSON response. Stedi uses it to generate and submit the 275 claim attachment transaction to the payer.

• This property is required when you're submitting attachment files through Stedi.
• You must include either this property or attachmentControlNumber in the request, but not both. Including both properties will result in an error.

attachmentReportTypeCode · claimInformation.claimSupplementalInformation.reportInformations[].attachmentReportTypeCode · String Required

Code indicating the title or contents of a document, report or supporting item. For example, B4 - Referral Form or DA - Dental Models. Visit Claims code lists for a complete list.

Possible values

B4

DA

DG

EB

OZ

attachmentTransmissionCode · claimInformation.claimSupplementalInformation.reportInformations[].attachmentTransmissionCode · String Required

Code identifying the method by which the provider's report is attached. Can be set to AA - Available on Request at Provider Site, BM - By Mail, EL - Electronically Only, EM - E-Mail, FT - File Transfer, or FX - By Fax.

Set this to EL when you plan to submit attachments electronically through Stedi APIs.

Possible values

AA

BM

EL

EM

FT

repricedClaimNumber · claimInformation.claimSupplementalInformation.repricedClaimNumber · String

Required when the repricer believes this information is necessary. Providers should not complete this property.

serviceAuthorizationExceptionCode · claimInformation.claimSupplementalInformation.serviceAuthorizationExceptionCode · String

Code indicating the reason for the service authorization exception. Visit Claims code lists for a complete list.

Possible values

1

2

3

4

5

delayReasonCode · claimInformation.delayReasonCode · String

Code indicating the reason for the delay in claim submission. Visit Claims code lists for a complete list.

Possible values

1

2

3

4

5

fileInformation · claimInformation.fileInformation · String Deprecated

Please use the fileInformationList array instead.

fileInformationList · claimInformation.fileInformationList · Array of Strings Items: 1 - 10

An array of additional information items the payer requested. Not commonly used.

healthCareCodeInformation · claimInformation.healthCareCodeInformation · Array of Objects Items: 1 - 4

Details about the patient's healthcare diagnosis. Only required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions.

• Use ABK as the type for the principal diagnosis code and ABF for any other diagnosis codes you include.
• Use one ABK code as the first object, and then you can submit up to 3 ABF codes as needed. If you need to submit more codes than this, you must create additional, separate claims.

diagnosisCode · claimInformation.healthCareCodeInformation[].diagnosisCode · String Required

The diagnosis code.

• You must submit a valid, billable code at the highest level of specificity. Include the 4th - 7th characters as applicable.
• Don't submit the decimal point for ICD codes. The decimal point is implied.
• Don't submit ICD-10 header codes. Header codes exist to group related codes and aren't valid for billing. These header codes can change with each new version of ICD-10, so we recommend reviewing your diagnosis codes every year to ensure that they aren't classified as header codes in the most recent version. To determine whether a code is a header code, you can also search the Value Set Authority Center. If the 'Header' property is set, the code is a header code and you shouldn't use it in claim submissions.

diagnosisTypeCode · claimInformation.healthCareCodeInformation[].diagnosisTypeCode · String Required

Code indicating the specific industry code list. Can be set to ABK - International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis or ABF - International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis, TQ Systemized Nomenclature of Dentistry (SNODENT).

Possible values

ABK

ABF

TQ

orthodonticTotalMonthsOfTreatment · claimInformation.orthodonticTotalMonthsOfTreatment · Object

Information about orthodontic treatment. Required when the claim contains services related to treatment for orthodontic purposes. You must include one of these properties in this object: monthsCount, monthsRemaining, or treatmentIndicator.

monthsCount · claimInformation.orthodonticTotalMonthsOfTreatment.monthsCount · Number Format: double

The estimated number of treatment months, expressed as a decimal.

monthsRemaining · claimInformation.orthodonticTotalMonthsOfTreatment.monthsRemaining · Number Format: double

The number of months remaining in the treatment, expressed as a decimal.

treatmentIndicator · claimInformation.orthodonticTotalMonthsOfTreatment.treatmentIndicator · String

The only allowed value is Y, which indicates that services reported in this claim are for orthodontic purposes. Only include this property if you haven't set the monthsCount or monthsRemaining properties.

otherSubscriberInformation · claimInformation.otherSubscriberInformation · Array of Objects Items: 1 - 10

Required when other payers are known to potentially be involved in paying on this claim. This object contains information about other health plans under which the patient has coverage. It's used for coordination of benefits scenarios.

benefitsAssignmentCertificationIndicator · claimInformation.otherSubscriberInformation[].benefitsAssignmentCertificationIndicator · String Required

Code indicating whether or not the insured has authorized the plan to remit payment directly to the provider. Can be set to N - No (Payment should go to the patient), Y - Yes (Payment should go directly to the provider), or W - Not Applicable.

Possible values

N

W

Y

claimFilingIndicatorCode · claimInformation.otherSubscriberInformation[].claimFilingIndicatorCode · String

A code identifying the type of claim. For example DS - Disability. Use OF when submitting Medicare Part D claims. Use ZZ when you don't know the type of insurance. Visit Claims code lists for a complete list.

Possible values

11

12

13

14

15

claimLevelAdjustments · claimInformation.otherSubscriberInformation[].claimLevelAdjustments · Array of Objects Items: 1 - 5

Use this object to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, you must convert them to standard Claim Adjustment Reason Codes.

adjustmentDetails · claimInformation.otherSubscriberInformation[].claimLevelAdjustments[].adjustmentDetails · Array of Objects Required Items: 1 - 6

The adjustment reason codes and amounts. You can include up to six objects in this array to describe a single adjustment group code.

adjustmentAmount · claimInformation.otherSubscriberInformation[].claimLevelAdjustments[].adjustmentDetails[].adjustmentAmount · String Required Regex pattern: ^\d+(\.\d{1,2})?$

The dollar amount of the adjustment, expressed as a decimal. For example, 100.50.

adjustmentQuantity · claimInformation.otherSubscriberInformation[].claimLevelAdjustments[].adjustmentDetails[].adjustmentQuantity · String

The units of service being adjusted.

adjustmentReasonCode · claimInformation.otherSubscriberInformation[].claimLevelAdjustments[].adjustmentDetails[].adjustmentReasonCode · String Required

Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.

adjustmentGroupCode · claimInformation.otherSubscriberInformation[].claimLevelAdjustments[].adjustmentGroupCode · String Required

Code identifying the general category of payment adjustment. Can be set to CO - Contractual Obligations, CR - Correction and Reversals, OA - Other Adjustments, PI - Payor Initiated Reductions, or `PR - Patient Responsibility.

Possible values

CO

CR

OA

PI

PR

individualRelationshipCode · claimInformation.otherSubscriberInformation[].individualRelationshipCode · String Required

Code identifying the relationship to the person insured. Visit Claims code lists for a complete list.

Possible values

01

18

19

20

21

insuranceGroupOrPolicyNumber · claimInformation.otherSubscriberInformation[].insuranceGroupOrPolicyNumber · String

The group or policy number.

insuranceTypeCode · claimInformation.otherSubscriberInformation[].insuranceTypeCode · String

Code identifying the type of insurance policy within a specific insurance program. Visit Claims code lists for a complete list.

Possible values

12

13

14

15

16

medicareOutpatientAdjudication · claimInformation.otherSubscriberInformation[].medicareOutpatientAdjudication · Object

Claim-level data related to the adjudication of Medicare claims not related to an inpatient setting. Required when outpatient adjudication information is reported in the remittance advice or when you need to report remark codes.

claimPaymentRemarkCode · claimInformation.otherSubscriberInformation[].medicareOutpatientAdjudication.claimPaymentRemarkCode · Array of Strings Items: 1 - 5

The remark code. Visit the X12 Remittance Advice Remark Codes for a complete list. You can include up to five codes in this array.

hcpcsPayableAmount · claimInformation.otherSubscriberInformation[].medicareOutpatientAdjudication.hcpcsPayableAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount, expressed as a decimal.

nonPayableProfessionalComponentBilledAmount · claimInformation.otherSubscriberInformation[].medicareOutpatientAdjudication.nonPayableProfessionalComponentBilledAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The professional component amount billed but not payable, expressed as a decimal.

reimbursementRate · claimInformation.otherSubscriberInformation[].medicareOutpatientAdjudication.reimbursementRate · String

The reimbursement percentage, expressed as a decimal.

nonCoveredChargeAmount · claimInformation.otherSubscriberInformation[].nonCoveredChargeAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in otherSubscriberInformation.otherPayerName. The amount must equal the total claim charge amount you reported in claimInformation.claimChargeAmount.

otherInsuredGroupName · claimInformation.otherSubscriberInformation[].otherInsuredGroupName · String

The name of the health plan.

otherPayerAssistantSurgeon · claimInformation.otherSubscriberInformation[].otherPayerAssistantSurgeon · Object

Information about the assistant surgeon.

entityTypeQualifier · claimInformation.otherSubscriberInformation[].otherPayerAssistantSurgeon.entityTypeQualifier · String Required

Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity. In practice, you should always set this to 1 - Person.

Possible values

1

2

otherPayerAssistantSurgeonIdentifier · claimInformation.otherSubscriberInformation[].otherPayerAssistantSurgeon.otherPayerAssistantSurgeonIdentifier · Array of Objects Required Items: 1 - 3

An identifier for the assistant surgeon.

identifier · claimInformation.otherSubscriberInformation[].otherPayerAssistantSurgeon.otherPayerAssistantSurgeonIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.otherSubscriberInformation[].otherPayerAssistantSurgeon.otherPayerAssistantSurgeonIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.otherSubscriberInformation[].otherPayerAssistantSurgeon.otherPayerAssistantSurgeonIdentifier[].qualifier · String Required

Set to 0B - State License Number, 1G - Provider UPIN Number, G2 - Commercial Number, or LU - Location Number. Note that UPIN is deprecated and shouldn't be used in new claims.

otherPayerBillingProvider · claimInformation.otherSubscriberInformation[].otherPayerBillingProvider · Array of Objects

Information about the billing provider.

entityTypeQualifier · claimInformation.otherSubscriberInformation[].otherPayerBillingProvider[].entityTypeQualifier · String Required

Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.

Possible values

1

2

otherPayerBillingProviderIdentifier · claimInformation.otherSubscriberInformation[].otherPayerBillingProvider[].otherPayerBillingProviderIdentifier · Array of Objects Required Items: 1 - 2

Identifiers for the billing provider.

identifier · claimInformation.otherSubscriberInformation[].otherPayerBillingProvider[].otherPayerBillingProviderIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.otherSubscriberInformation[].otherPayerBillingProvider[].otherPayerBillingProviderIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.otherSubscriberInformation[].otherPayerBillingProvider[].otherPayerBillingProviderIdentifier[].qualifier · String Required

Set to LU - Location Number, or G2 - Provider Commercial Number.

otherPayerName · claimInformation.otherSubscriberInformation[].otherPayerName · Object Required

Details about the other payer.

otherPayerAddress · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress · Object

The payer's address.

address1 · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress.city · String Required

The city name.

countryCode · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAddress.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

otherPayerAdjudicationOrPaymentDate · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerAdjudicationOrPaymentDate · String

The date the other payer adjudicated the claim. Required when this payer has previously adjudicated the claim and you aren’t including a value for LineAdjudicationInformation.adjudicationOrPaymentDate.

otherPayerClaimAdjustmentIndicator · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerClaimAdjustmentIndicator · Boolean

The only valid value is true. Required when Required when the claim is being sent in the payer-to-payer COB model AND the destination payer is secondary to this payer AND this payer has re-adjudicated the claim.

otherPayerClaimControlNumber · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerClaimControlNumber · String

The claim control number assigned by this payer.

otherPayerIdentifier · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier · String Required

The identifier specified in otherPayerIdentifierCode. When sending Line Adjudication Information for this payer, the identifier sent in lineAdjudicationInformation.otherPayerPrimaryIdentifier must match this value.

otherPayerIdentifierTypeCode · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifierTypeCode · String Required

Code designating the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Possible values

PI

XV

otherPayerOrganizationName · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerOrganizationName · String Required

The payer's organization name.

otherPayerPredeterminationIdentification · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerPredeterminationIdentification · String

The authorization number assigned by this payer.

otherPayerPriorAuthorizationNumber · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerPriorAuthorizationNumber · String

The authorization number assigned by this payer.

otherPayerPriorAuthorizationOrReferralNumber · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerPriorAuthorizationOrReferralNumber · String

The referral number assigned by this payer.

otherPayerSecondaryIdentifier · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerSecondaryIdentifier · Array of Objects Items: 1 - 2

An additional identification number to identify the other payer.

identifier · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerSecondaryIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerSecondaryIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerSecondaryIdentifier[].qualifier · String Required

Set to 2U - Payer Identification Number, EI - Employer Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners (NAIC) Code.

otherPayerReferringProvider · claimInformation.otherSubscriberInformation[].otherPayerReferringProvider · Array of Objects

Information about the provider who directed the patient to the rendering provider for care. For example, a primary care physician may refer patients to a specialist.

otherPayerReferringProviderIdentifier · claimInformation.otherSubscriberInformation[].otherPayerReferringProvider[].otherPayerReferringProviderIdentifier · Array of Objects Required Items: 1 - 3

Identifiers for the referring provider.

identifier · claimInformation.otherSubscriberInformation[].otherPayerReferringProvider[].otherPayerReferringProviderIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.otherSubscriberInformation[].otherPayerReferringProvider[].otherPayerReferringProviderIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.otherSubscriberInformation[].otherPayerReferringProvider[].otherPayerReferringProviderIdentifier[].qualifier · String Required

Set to 0B - State License Number, 1G - Provider UPIN Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.

otherPayerRenderingProvider · claimInformation.otherSubscriberInformation[].otherPayerRenderingProvider · Array of Objects

Information about the rendering provider.

entityTypeQualifier · claimInformation.otherSubscriberInformation[].otherPayerRenderingProvider[].entityTypeQualifier · String Required

Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.

Possible values

1

2

otherPayerRenderingProviderSecondaryIdentifier · claimInformation.otherSubscriberInformation[].otherPayerRenderingProvider[].otherPayerRenderingProviderSecondaryIdentifier · Array of Objects Items: 1 - 3

Identifiers for the rendering provider.

identifier · claimInformation.otherSubscriberInformation[].otherPayerRenderingProvider[].otherPayerRenderingProviderSecondaryIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.otherSubscriberInformation[].otherPayerRenderingProvider[].otherPayerRenderingProviderSecondaryIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.otherSubscriberInformation[].otherPayerRenderingProvider[].otherPayerRenderingProviderSecondaryIdentifier[].qualifier · String Required

Set to 0B - State License Number, 1G - Provider UPIN Number, LU - Location Number, or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.

otherPayerServiceFacilityLocation · claimInformation.otherSubscriberInformation[].otherPayerServiceFacilityLocation · Array of Objects

Information about the service facility location.

otherPayerServiceFacilityLocationSecondaryIdentifier · claimInformation.otherSubscriberInformation[].otherPayerServiceFacilityLocation[].otherPayerServiceFacilityLocationSecondaryIdentifier · Array of Objects Required Items: 1 - 3

A secondary identifier for the service facility location.

identifier · claimInformation.otherSubscriberInformation[].otherPayerServiceFacilityLocation[].otherPayerServiceFacilityLocationSecondaryIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.otherSubscriberInformation[].otherPayerServiceFacilityLocation[].otherPayerServiceFacilityLocationSecondaryIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.otherSubscriberInformation[].otherPayerServiceFacilityLocation[].otherPayerServiceFacilityLocationSecondaryIdentifier[].qualifier · String Required

Set to 0B - State License Number, LU - Location Number, or G2 - Provider Commercial Number.

otherPayerSupervisingProvider · claimInformation.otherSubscriberInformation[].otherPayerSupervisingProvider · Array of Objects

Information about the supervising provider.

otherPayerSupervisingProviderIdentifier · claimInformation.otherSubscriberInformation[].otherPayerSupervisingProvider[].otherPayerSupervisingProviderIdentifier · Array of Objects Required Items: 1 - 3

Identifiers for the supervising provider.

identifier · claimInformation.otherSubscriberInformation[].otherPayerSupervisingProvider[].otherPayerSupervisingProviderIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.otherSubscriberInformation[].otherPayerSupervisingProvider[].otherPayerSupervisingProviderIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.otherSubscriberInformation[].otherPayerSupervisingProvider[].otherPayerSupervisingProviderIdentifier[].qualifier · String Required

Set to 0B - State License Number, 1G - Provider UPIN Number, LU - Location Number or G2 - Provider Commercial Number. Note that UPIN is deprecated and shouldn't be used for new claims.

otherSubscriberName · claimInformation.otherSubscriberInformation[].otherSubscriberName · Object Required

The person or entity who is the primary policyholder for the other payer's health plan.

otherInsuredAdditionalIdentifiers · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAdditionalIdentifiers · Array of Strings Items: 1 - 2

The primary policyholder's Social Security Number. The Social Security Number must be a string of exactly nine numbers with no separators. For example 123456789.

otherInsuredAddress · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress · Object

The other subscriber's address.

address1 · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress.city · String Required

The city name.

countryCode · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredAddress.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

otherInsuredFirstName · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredFirstName · String

The primary policyholder's first name, if they are an individual.

otherInsuredIdentifier · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredIdentifier · String Required

The identifier you specified in otherInsuredIdentifierTypeCode.

otherInsuredIdentifierTypeCode · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredIdentifierTypeCode · String Required

Code identifying the type of identifier. Can be set to II - Standard Unique Health Identifier for each individual in the United States or MI - Member Identification Number. The code MI should be the subscriber's identification number as assigned by the payer, such as their subscriber ID. You should also use MI in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). For IHS/CHS claims, you should also put the SSN in the otherInsuredAdditionalIdentifier property.)

Possible values

II

MI

otherInsuredLastName · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredLastName · String Required

The primary policyholder's last name or organizational name. Don't include the primary policyholder's name suffix, such as Jr. or III. Use the designated otherInsuredNameSuffix property instead.

otherInsuredMiddleName · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredMiddleName · String

The primary policyholder's middle name or initial, if they are an individual.

otherInsuredNameSuffix · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredNameSuffix · String

The primary policyholder's name suffix, such as Jr. or III. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

otherInsuredQualifier · claimInformation.otherSubscriberInformation[].otherSubscriberName.otherInsuredQualifier · String Required

Code identifying the type of entity. Can be set to 1 - Person or 2 - Non-Person Entity.

Possible values

1

2

payerPaidAmount · claimInformation.otherSubscriberInformation[].payerPaidAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The total amount in dollars the payer has paid on this claim. It is acceptable to set this to 0 (Zero). This is required when you include the payToPlan object, and you should set it to the amount the Medicaid agency actually paid.

paymentResponsibilityLevelCode · claimInformation.otherSubscriberInformation[].paymentResponsibilityLevelCode · String Required

Code identifying the payer's level of responsibility for paying this claim. Visit Claims code lists for a complete list.

• Either this property or subscriber.paymentResponsibilityLevelCode must be set to P to indicate the primary insurance payer. Stedi rejects claims - including secondary and tertiary claims - that don't include information for the primary payer.
• You may need to use other codes if the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill the commercial payer first as P and then bill the Medicare payer second as S.

Possible values

A

B

C

D

E

releaseOfInformationCode · claimInformation.otherSubscriberInformation[].releaseOfInformationCode · String Required

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to I - Informed Consent to Release Medical Information or Y - Yes. Code I is required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Code Y is required when the provider has collected a signature OR when state or federal laws require a signature be collected.

Possible values

I

Y

remainingPatientLiability · claimInformation.otherSubscriberInformation[].remainingPatientLiability · String Regex pattern: ^\d+(\.\d{1,2})?$

This is the remaining amount (as determined by the provider) to be paid after the other payer identified in the otherPayerName object has adjudicated the claim.

patientAmountPaid · claimInformation.patientAmountPaid · String Regex pattern: ^\d+(\.\d{1,2})?$

The total amount in dollars the patient or their representatives have paid on this claim. For example, 20.50. This includes any co-payments, co-insurance, or other amounts already collected from the patient.

If the patient has not paid anything, you should omit this property entirely - don't set it to 0.

patientControlNumber · claimInformation.patientControlNumber · String Required Length: 1 - 20

An identifier you assign to the claim. We strongly recommend submitting a unique value for this property so you can use it to correlate this claim with responses, such as the 277CA and 835 ERA.

• We recommend using only alphanumeric characters and generating unique values that are the shortest possible length. Stedi accepts any valid value, but some payers replace non-alphanumeric characters and truncate shorter than the official 20-character limit. When this happens, the payer returns a different identifier in responses than the one you originally sent, making it more difficult to correlate the claim and perform real-time claim status checks.
• If you plan to submit the autogenerated CMS-1500 PDF for this claim, you must limit this value to 14 characters or this value will be truncated in the PDF.

placeOfServiceCode · claimInformation.placeOfServiceCode · String Required

Code identifying the type of facility where the services were or may be performed. Visit Place of Service Codes for a complete list.

Possible values

01

02

03

04

05

planParticipationCode · claimInformation.planParticipationCode · String

The code indicating whether the provider accepts assignment in their relationship with the payer. Can be set to A - Assigned or C - Not Assigned. Code A is required when either the provider accepts assignment or has a participation agreement with the payer OR when the provider doesn't accept assignment or have a participation agreement but is advising the payer to adjudicate this specific claim under participating provider benefits allowed in certain plans.

Note that this is not where you should indicate whether the patient has assigned benefits to the provider - you must indicate that in the benefitsAssignmentCertificationIndicator property.

Possible values

A

C

predeterminationOfBenefits · claimInformation.predeterminationOfBenefits · Boolean

Required when the entire claim is being submitted as a predetermination of benefits. Predetermination of benefits claims are submitted in advance of services to get an estimate of what the patient's health plan will pay.

• Can be set to true to indicate predetermination of dental benefits.
• Not all dental payers support predetermination of benefits claims.
• Some payers prohibit setting claimInformation.claimDateInformation.serviceDate for predetermination of benefits claims. Refer to your payer's specific guidelines for more information.

propertyCasualtyClaimNumber · claimInformation.propertyCasualtyClaimNumber · String

The agency claim number for this transaction. Used when services included in this claim are part of a property and casualty claim.

relatedCausesCode · claimInformation.relatedCausesCode · Array of Strings Items: 1 - 2

Code identifying an accompanying cause of an illness, injury or an accident. Can be set to AA - Auto Accident, EM - Employment, or OA - Other Accident. You can include up to two codes in this array.

Possible values

AA

EM

OA

releaseInformationCode · claimInformation.releaseInformationCode · String Required

Indicates whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Can be set to Y - Yes, or I - Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues. Use I when the provider has not collected a signature AND state or federal laws do not require a signature be collected.

Possible values

I

Y

serviceFacilityLocation · claimInformation.serviceFacilityLocation · Object

Required when the location for the service is different from the billing provider's address. The purpose of this object is to identify specifically where the service was rendered. This can be healthcare facilities, such as surgical centers or reference labs, OR the patient's address when services were rendered in their home. - Only include this object when the service facility location is different from the billing provider's address. If you include this object when the address is the same, Stedi omits all of the service facility location information from the claim submission, including the name and any identifiers. - Sometimes the billing provider is an actual physician group that is located at the same address as a hospital, but is in fact a separate entity. In this case, you can differentiate the service facility location by including the specific suite or building number of the physician group. This ensures that the service facility location is different from the billing provider's address and is reported accurately.

address · claimInformation.serviceFacilityLocation.address · Object Required

The address of where services were rendered.

If the service facility location is in an area where there are no street addresses, enter a description of where the service was rendered. For example, 'crossroad of State Road 34 and 45'.

For United States addresses, you must include the full nine-digit zip code with no separators, such as 100031502. If you don't know the full zip code, you can find it using the USPS ZIP Code Lookup tool.

address1 · claimInformation.serviceFacilityLocation.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · claimInformation.serviceFacilityLocation.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · claimInformation.serviceFacilityLocation.address.city · String Required

The city name.

countryCode · claimInformation.serviceFacilityLocation.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · claimInformation.serviceFacilityLocation.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · claimInformation.serviceFacilityLocation.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · claimInformation.serviceFacilityLocation.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

npi · claimInformation.serviceFacilityLocation.npi · String Regex pattern: ^\d{10}$

The organization National Provider Identifier (NPI) assigned to the service facility. Only include this property when the service facility is not a component or subpart of the billing provider. Don't include when the service facility is the patient's home.

organizationName · claimInformation.serviceFacilityLocation.organizationName · String Required

The laboratory or facility name. When services were rendered in the patient's home, we recommend setting this to Residence or something similar.

phoneExtension · claimInformation.serviceFacilityLocation.phoneExtension · String

The telephone extension, if applicable. Only submit the numeric extension. For example, don't include data that indicates an extension, such as 'ext.' or 'x-'.

phoneName · claimInformation.serviceFacilityLocation.phoneName · String

The full name of the person or office.

phoneNumber · claimInformation.serviceFacilityLocation.phoneNumber · String

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.

secondaryIdentifier · claimInformation.serviceFacilityLocation.secondaryIdentifier · Array of Objects Items: 1 - 3

Secondary identifiers for the service facility location. Used when another identifier is needed for the claims processor to identify the facility or when the entity is not a healthcare provider and does not have an NPI.

identifier · claimInformation.serviceFacilityLocation.secondaryIdentifier[].identifier · String Required

The identifier. The format and length of this value depends on the qualifier you set.

otherIdentifier · claimInformation.serviceFacilityLocation.secondaryIdentifier[].otherIdentifier · String Deprecated

The identifier for the other payer who provided this reference number. This is only required when the reference number is provided by the non-destination payer. The value must match the claimInformation.otherSubscriberInformation[].otherPayerName.otherPayerIdentifier property.

qualifier · claimInformation.serviceFacilityLocation.secondaryIdentifier[].qualifier · String Required

Set to 0B - State License Number, LU - Location Number, or G2 - Provider Commercial Number.

serviceLines · claimInformation.serviceLines · Array of Objects Required

Information about one or more services rendered to the patient. - Each service line must be a unique service event as defined by the payer's billing policies. This means that you can use the same procedure code on multiple service lines as long as they are distinct events. - Some procedure codes are date-specific. In these cases, you may need to create a separate service line with that code for each applicable date of service, even if the episode of care extended over multiple days. - Service lines can share the same dates of service if the patient received multiple services on the same day.

assistantSurgeon · claimInformation.serviceLines[].assistantSurgeon · Object

Information about the assistant surgeon who rendered the care. Use this object when the rendering providers provided these services in the role of the assistant surgeon.

This should be an individual, not an organization, and you should supply at least the surgeon's lastName and an identifier, which is typically the npi.

commercialNumber · claimInformation.serviceLines[].assistantSurgeon.commercialNumber · String

The provider's commercial number.

firstName · claimInformation.serviceLines[].assistantSurgeon.firstName · String

The provider's first name.

lastName · claimInformation.serviceLines[].assistantSurgeon.lastName · String

The provider's last name.

locationNumber · claimInformation.serviceLines[].assistantSurgeon.locationNumber · String

The provider's location number.

middleName · claimInformation.serviceLines[].assistantSurgeon.middleName · String

The provider's middle name or initial.

npi · claimInformation.serviceLines[].assistantSurgeon.npi · String Regex pattern: ^\d{10}$

The individual National Provider Identifier (NPI) assigned to the provider.

organizationName · claimInformation.serviceLines[].assistantSurgeon.organizationName · String

The provider's business name.

providerUpinNumber · claimInformation.serviceLines[].assistantSurgeon.providerUpinNumber · String

Deprecated; do not use.

stateLicenseNumber · claimInformation.serviceLines[].assistantSurgeon.stateLicenseNumber · String

The provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · claimInformation.serviceLines[].assistantSurgeon.suffix · String

The provider's name suffix, such as Jr. or III.

taxonomyCode · claimInformation.serviceLines[].assistantSurgeon.taxonomyCode · String Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.

contractInformation · claimInformation.serviceLines[].contractInformation · Object

Required when the submitter is contractually obligated to supply this information on post-adjudicated claims.

contractAmount · claimInformation.serviceLines[].contractInformation.contractAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The total dollar amount of the contract, expressed as a decimal. For example, 100.50.

contractCode · claimInformation.serviceLines[].contractInformation.contractCode · String

The contract code. This is an identifier for the contract.

contractPercentage · claimInformation.serviceLines[].contractInformation.contractPercentage · String

The allowance or charge percent, expressed as a decimal. For example, 0.80.

contractTypeCode · claimInformation.serviceLines[].contractInformation.contractTypeCode · String Required

Code indicating the type of contract. Can be set to 02 - Per Diem, 03 - Variable Per Diem, 04 - Flat, 05 - Capitated, 06 - Percent, or 09 - Other.

Possible values

02

03

04

05

06

contractVersionIdentifier · claimInformation.serviceLines[].contractInformation.contractVersionIdentifier · String

An additional identifier for the contract. Identifies the revision level of a particular format, program, technique or algorithm.

termsDiscountPercentage · claimInformation.serviceLines[].contractInformation.termsDiscountPercentage · String

Terms discount percentage, expressed as a decimal, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date.

dentalService · claimInformation.serviceLines[].dentalService · Object Required

Information about the service rendered to the patient, including the procedure code, the line item charge amount, and the place of service.

compositeDiagnosisCodePointers · claimInformation.serviceLines[].dentalService.compositeDiagnosisCodePointers · Object

Diagnosis code pointers in order of importance to this service line. These pointers are an index to the ICD-10-CM codes you included in the claimInformation.healthCareCodeInformation object array. The pointer values can be from 1 to 12 (integer numbers).

• You must set at least one pointer for the primary diagnosis. Then, you can add up to three additional pointers (up to four in total).
• The number of pointers cannot exceed the number of diagnosis codes in the claimInformation.healthCareCodeInformation object array. For example, if you only supplied one diagnosis code, then the only valid pointer value is 1.
• Don't put ICD-10-CM codes here - they belong in claimInformation.healthCareCodeInformation.

diagnosisCodePointers · claimInformation.serviceLines[].dentalService.compositeDiagnosisCodePointers.diagnosisCodePointers · Array of Strings Required Items: 1 - 2147483647

A diagnosis code pointer for this service line.

description · claimInformation.serviceLines[].dentalService.description · String Length: 1 - 80

A free form description to clarify the procedure code and any procedure modifiers, as needed.

lineItemChargeAmount · claimInformation.serviceLines[].dentalService.lineItemChargeAmount · String Required Regex pattern: ^\d+(\.\d{1,2})?$

The total charge amount for the service, including the provider's base charge and any applicable tax or postage. It is acceptable to set this to 0 (zero).

oralCavityDesignation · claimInformation.serviceLines[].dentalService.oralCavityDesignation · Array of Strings Items: 1 - 5

Required when the nomenclature associated with the procedure reported in claimInformation.serviceLines.dentalService.procedureCode refers to a quadrant or arch and the area of the oral cavity is not uniquely defined.

• You can include up to five codes per service line.
• You should report individual tooth numbers in one or more teethInformation objects.

placeOfServiceCode · claimInformation.serviceLines[].dentalService.placeOfServiceCode · String

Code identifying the type of facility where the services were or may be performed. Visit Place of Service Codes for a complete list.

procedureCode · claimInformation.serviceLines[].dentalService.procedureCode · String Required

The procedure code.

procedureCount · claimInformation.serviceLines[].dentalService.procedureCount · Number Format: double

The number of procedures performed.

procedureModifiers · claimInformation.serviceLines[].dentalService.procedureModifiers · Array of Strings Items: 1 - 4

Modifier codes that clarify or improve the reporting accuracy of the associated procedure code. You can include up to four modifiers in this array. Only include modifier codes when required; otherwise, do not send.

prosthesisCrownOrInlayCode · claimInformation.serviceLines[].dentalService.prosthesisCrownOrInlayCode · String

Code indicating the placement status for the dental work. Can be set to I - Initial Placement or R - Replacement. When set to R, you must include either the priorPlacementDate or estimatedPriorPlacementDate properties within the claimInformation.serviceLines.serviceLineDateInformation object.

Possible values

I

R

fileInformation · claimInformation.serviceLines[].fileInformation · Array of Strings Items: 1 - 10

Used to send additional data specifically requested by the payer. Not commonly used.

lineAdjudicationInformation · claimInformation.serviceLines[].lineAdjudicationInformation · Array of Objects

Includes service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers.

adjudicationOrPaymentDate · claimInformation.serviceLines[].lineAdjudicationInformation[].adjudicationOrPaymentDate · String Required Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the other payer adjudicated or paid the claim.

bundledOrUnbundledLineNumber · claimInformation.serviceLines[].lineAdjudicationInformation[].bundledOrUnbundledLineNumber · String

The LX assigned number of the service line into which this service line is bundled. It's only used to bundle service lines.

claimAdjustmentInformation · claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation · Array of Objects Items: 1 - 5

Required when the payer made line level adjustments which caused the amount paid to differ from the amount originally charged. You can include up to five objects in this array.

adjustmentDetails · claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation[].adjustmentDetails · Array of Objects Required Items: 1 - 6

The adjustment reason codes and amounts. You can include up to six objects in this array to describe a single adjustment group code.

adjustmentAmount · claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation[].adjustmentDetails[].adjustmentAmount · String Required Regex pattern: ^\d+(\.\d{1,2})?$

The dollar amount of the adjustment, expressed as a decimal. For example, 100.50.

adjustmentQuantity · claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation[].adjustmentDetails[].adjustmentQuantity · String

The units of service being adjusted.

adjustmentReasonCode · claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation[].adjustmentDetails[].adjustmentReasonCode · String Required

Code identifying the detailed reason the adjustment was made. Visit the X12 Claim Adjustment Reason Codes for a complete list.

adjustmentGroupCode · claimInformation.serviceLines[].lineAdjudicationInformation[].claimAdjustmentInformation[].adjustmentGroupCode · String Required

Code identifying the general category of payment adjustment. Can be set to CO - Contractual Obligations, CR - Correction and Reversals, OA - Other Adjustments, PI - Payor Initiated Reductions, or `PR - Patient Responsibility.

Possible values

CO

CR

OA

PI

PR

otherPayerPrimaryIdentifier · claimInformation.serviceLines[].lineAdjudicationInformation[].otherPayerPrimaryIdentifier · String Required

The payer ID for the payer responsible for reimbursement.

paidServiceUnitCount · claimInformation.serviceLines[].lineAdjudicationInformation[].paidServiceUnitCount · String Required

The number of paid units from the remittance advice. expressed as a decimal. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this property is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.

procedureCode · claimInformation.serviceLines[].lineAdjudicationInformation[].procedureCode · String Required

The procedure code.

procedureCodeDescription · claimInformation.serviceLines[].lineAdjudicationInformation[].procedureCodeDescription · String

The meaning of the procedure code.

procedureModifier · claimInformation.serviceLines[].lineAdjudicationInformation[].procedureModifier · Array of Strings Items: 1 - 4

Modifiers that convey special circumstances related to the performance of the service. You can include up to four modifiers in this array.

remainingPatientLiability · claimInformation.serviceLines[].lineAdjudicationInformation[].remainingPatientLiability · String Regex pattern: ^\d+(\.\d{1,2})?$

The amount of the service line that the patient is still responsible for, expressed as a decimal.

serviceIdQualifier · claimInformation.serviceLines[].lineAdjudicationInformation[].serviceIdQualifier · String Required

Code identifying the the type of product or service ID. Can be set to AD - American Dental Association Codes or ER - Jurisdiction Specific Procedure and Supply Codes.

Possible values

AD

ER

serviceLinePaidAmount · claimInformation.serviceLines[].lineAdjudicationInformation[].serviceLinePaidAmount · String Required Regex pattern: ^\d+(\.\d{1,2})?$

The amount paid for this service line, expressed as a decimal. Zero (0) is an acceptable value.

linePricingRepricingInformation · claimInformation.serviceLines[].linePricingRepricingInformation · Object

Repricing information about the line item. This information is completed by repricers, not providers. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

exceptionCode · claimInformation.serviceLines[].linePricingRepricingInformation.exceptionCode · String

Code specifying the exception reason for consideration of out-of-network health care services. This is the reason generated by the third-party health organization. Visit Claims code lists for a complete list.

Possible values

1

2

3

4

5

measurementUnitCode · claimInformation.serviceLines[].linePricingRepricingInformation.measurementUnitCode · String

The unit of measure for the service that was repriced. Can be set to UN - Units.

Possible values

UN

policyComplianceCode · claimInformation.serviceLines[].linePricingRepricingInformation.policyComplianceCode · String

Code indicating the policy compliance status of the claim. Visit Claims code lists for a complete list.

Possible values

1

2

3

4

5

pricingMethodologyCode · claimInformation.serviceLines[].linePricingRepricingInformation.pricingMethodologyCode · String Required

Code indicating the pricing or repricing methodology. Visit Claims code lists for a complete list.

Possible values

00

01

02

03

04

rejectReasonCode · claimInformation.serviceLines[].linePricingRepricingInformation.rejectReasonCode · String

Code indicating the rejection message returned from the third party organization. Visit Claims code lists for a complete list.

Possible values

T1

T2

T3

T4

T5

repricedAllowedAmount · claimInformation.serviceLines[].linePricingRepricingInformation.repricedAllowedAmount · String Required Regex pattern: ^\d+(\.\d{1,2})?$

The dollar amount, expressed as a decimal. For example, 100.50.

repricedApprovedHCPCSCode · claimInformation.serviceLines[].linePricingRepricingInformation.repricedApprovedHCPCSCode · String

The procedure code for the service that was repriced.

repricedApprovedServiceUnitCount · claimInformation.serviceLines[].linePricingRepricingInformation.repricedApprovedServiceUnitCount · Number Format: double

The number of units for the service that was repriced, expressed as a decimal. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three.

repricedSavingAmount · claimInformation.serviceLines[].linePricingRepricingInformation.repricedSavingAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The dollar amount, expressed as a decimal.

repricingOrganizationIdentifier · claimInformation.serviceLines[].linePricingRepricingInformation.repricingOrganizationIdentifier · String

The identifier of the organization that repriced the claim.

repricingPerDiemOrFlatRateAmount · claimInformation.serviceLines[].linePricingRepricingInformation.repricingPerDiemOrFlatRateAmount · String

The pricing rate associated with per diem or flat rate repricing, expressed as a decimal.

serviceIdQualifier · claimInformation.serviceLines[].linePricingRepricingInformation.serviceIdQualifier · String

The qualifier for the type of code included in repricedApprovedHCPCSCode. Can be set to AD - American Dental Association Codes.

Possible values

AD

postageTaxAmount · claimInformation.serviceLines[].postageTaxAmount · String Regex pattern: ^\d+(\.\d{1,2})?$

The amount of the postage, formatted as a decimal. When you include this property, the total lineItemChargeAmount for this service line must include this postage value.

providerControlNumber · claimInformation.serviceLines[].providerControlNumber · String

A unique identifier for this service line within the claim. It appears in the 835 (ERA) response as lineItemControlNumber, allowing you to correlate ERAs to the specific service lines from the original claim. If you don't set this property, Stedi uses a random ULID. Stedi returns service line identifiers in the claimReference.serviceLines.lineItemControlNumber object of the synchronous API response.

renderingProvider · claimInformation.serviceLines[].renderingProvider · Object

Information about the provider who rendered the services. This can be a individual or a company (a laboratory or other facility). This is where you should enter the substitute provider's (locum tenens physician) information, if applicable.

You should only include this object when the rendering provider information for this service line is different than the information listed in the rendering object for the entire claim.

commercialNumber · claimInformation.serviceLines[].renderingProvider.commercialNumber · String

The provider's commercial number.

firstName · claimInformation.serviceLines[].renderingProvider.firstName · String

The provider's first name.

lastName · claimInformation.serviceLines[].renderingProvider.lastName · String

The provider's last name.

locationNumber · claimInformation.serviceLines[].renderingProvider.locationNumber · String

The provider's location number.

middleName · claimInformation.serviceLines[].renderingProvider.middleName · String

The provider's middle name or initial.

npi · claimInformation.serviceLines[].renderingProvider.npi · String Regex pattern: ^\d{10}$

The National Provider Identifier (NPI) assigned to the provider.

organizationName · claimInformation.serviceLines[].renderingProvider.organizationName · String

The provider's business name.

providerUpinNumber · claimInformation.serviceLines[].renderingProvider.providerUpinNumber · String

Deprecated; do not use.

stateLicenseNumber · claimInformation.serviceLines[].renderingProvider.stateLicenseNumber · String

The provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · claimInformation.serviceLines[].renderingProvider.suffix · String

The provider's name suffix, such as Jr. or III.

taxonomyCode · claimInformation.serviceLines[].renderingProvider.taxonomyCode · String Required Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.

salesTaxAmount · claimInformation.serviceLines[].salesTaxAmount · String

Sales tax, formatted as a decimal. When you include this property, the total lineItemChargeAmount for this service line must include this sales tax value.

serviceDate · claimInformation.serviceLines[].serviceDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the service was rendered (for services performed on a single day),. Do not supply a date here if you are including the serviceLineDateInformation.treatmentStartDate property in the service line.

serviceFacilityLocation · claimInformation.serviceLines[].serviceFacilityLocation · Object

Information about where the services were rendered. This can be healthcare facilities, such as surgical centers or reference labs, OR the patient's address when services were rendered in their home. - Only include this object when the service facility location is different from the billing provider's address. If you include this object when the address is the same, Stedi omits all of the service facility location information from the claim submission, including the name and any identifiers. - Sometimes the billing provider is an actual physician group that is located at the same address as a hospital, but is in fact a separate entity. In this case, you can differentiate the service facility location by including the specific suite or building number of the physician group. This ensures that the service facility location is different from the billing provider's address and is reported accurately.

address · claimInformation.serviceLines[].serviceFacilityLocation.address · Object

address1 · claimInformation.serviceLines[].serviceFacilityLocation.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · claimInformation.serviceLines[].serviceFacilityLocation.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · claimInformation.serviceLines[].serviceFacilityLocation.address.city · String Required

The city name.

countryCode · claimInformation.serviceLines[].serviceFacilityLocation.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · claimInformation.serviceLines[].serviceFacilityLocation.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · claimInformation.serviceLines[].serviceFacilityLocation.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · claimInformation.serviceLines[].serviceFacilityLocation.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

commercialNumber · claimInformation.serviceLines[].serviceFacilityLocation.commercialNumber · String

The provider's commercial number.

locationNumber · claimInformation.serviceLines[].serviceFacilityLocation.locationNumber · String

The provider's location number.

npi · claimInformation.serviceLines[].serviceFacilityLocation.npi · String Regex pattern: ^\d{10}$

The organization National Provider Identifier (NPI) assigned to the service facility. Only include this property when the service facility is not a component or subpart of the billing provider. Don't include when the service facility is the patient's home.

organizationName · claimInformation.serviceLines[].serviceFacilityLocation.organizationName · String Required

The provider's business name.

providerUpinNumber · claimInformation.serviceLines[].serviceFacilityLocation.providerUpinNumber · String

Deprecated; do not use.

serviceLineDateInformation · claimInformation.serviceLines[].serviceLineDateInformation · Object

Identify specific dates related to the service rendered.

applianceDate · claimInformation.serviceLines[].serviceLineDateInformation.applianceDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the appliance was placed. Required when the orthodontic appliance placement date is different than the date you supplied in claimInformation.claimDateInformation.appliancePlacementDate.

estimatedPriorPlacementDate · claimInformation.serviceLines[].serviceLineDateInformation.estimatedPriorPlacementDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The estimated date when the previous appliance was placed. Either this property or priorPlacementDate is required when the claimInformation.serviceLines.dentalService.prosthesisCrownOrInlayCode for this service line is set to R for Replacement.

priorPlacementDate · claimInformation.serviceLines[].serviceLineDateInformation.priorPlacementDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The exact date when the previous appliance was placed. Either this property or estimatedPriorPlacementDate is required when the claimInformation.serviceLines.dentalService.prosthesisCrownOrInlayCode for this service line is set to R for Replacement.

replacementDate · claimInformation.serviceLines[].serviceLineDateInformation.replacementDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the orthodontic appliance was replaced.

treatmentCompletionDate · claimInformation.serviceLines[].serviceLineDateInformation.treatmentCompletionDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the treatment was completed. If you include this property, do not include the serviceDate property in this service line.

treatmentStartDate · claimInformation.serviceLines[].serviceLineDateInformation.treatmentStartDate · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The date the treatment began. This may apply to the following scenarios: initial impression or preparation for a crown or denture, reporting initial endontic treatment, or reporting the implant fixture placement. If you include this property, do not include the serviceDate property in this service line.

serviceLineReferenceInformation · claimInformation.serviceLines[].serviceLineReferenceInformation · Object

Additional identifiers for the service line.

adjustedRepricedLineItemReferenceNumber · claimInformation.serviceLines[].serviceLineReferenceInformation.adjustedRepricedLineItemReferenceNumber · String

Required when a repricing (pricing) organization needs to have an identifying number on the service line. Only completed by repricing organizations.

predeterminationOfBenefits · claimInformation.serviceLines[].serviceLineReferenceInformation.predeterminationOfBenefits · Array of Objects Items: 1 - 5

The Predetermination of Benefits Identification Numbers relevant to this service line. Required for services that have been previously predetermined and are now being submitted for payment. You can include up to five objects in this array.

otherPayerPrimaryIdentifier · claimInformation.serviceLines[].serviceLineReferenceInformation.predeterminationOfBenefits[].otherPayerPrimaryIdentifier · String

The primary identifier of the payer who assigned the predeterminationOfBenefits number. This must match the identifier in the claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifier property.

predeterminationOfBenefits · claimInformation.serviceLines[].serviceLineReferenceInformation.predeterminationOfBenefits[].predeterminationOfBenefits · String Required

The Predetermination of Benefits Identification Number. If you're including the identifier provided by the payer identified in claimInformation.otherSubscriberInformation.otherPayerName, you must also include the otherPayerPrimaryIdentifier property.

priorAuthorization · claimInformation.serviceLines[].serviceLineReferenceInformation.priorAuthorization · Array of Objects Items: 1 - 5

Prior authorization numbers relevant to this service line. Required when services have been previously authorized and are now being submitted for payment. You can include up to five objects in this array.

otherPayerPrimaryIdentifier · claimInformation.serviceLines[].serviceLineReferenceInformation.priorAuthorization[].otherPayerPrimaryIdentifier · String

This must match the value in claimInformation.otherSubscriberInformation.otherPayerName.otherPayerIdentifier.

priorAuthorizationOrReferralNumber · claimInformation.serviceLines[].serviceLineReferenceInformation.priorAuthorization[].priorAuthorizationOrReferralNumber · String Required

The prior authorization number.

Important: Only use this field for service-level prior authorization numbers that differ from the claim-level authorization (claimInformation.claimSupplementalInformation.priorAuthorizationNumber). If this value matches the claim-level value, only the claim-level authorization will appear in the X12 EDI transaction. Set claim-level authorizations first.

referralNumber · claimInformation.serviceLines[].serviceLineReferenceInformation.referralNumber · Array of Strings Items: 1 - 5

Required when this service line involved a referral number that is different than the number reported at the claim level. You can include up to five objects in this array.

repricedLineItemReferenceNumber · claimInformation.serviceLines[].serviceLineReferenceInformation.repricedLineItemReferenceNumber · String

Required when a repricing (pricing) organization needs to have an identifying number on the service line. Only completed by repricing organizations.

supervisingProvider · claimInformation.serviceLines[].supervisingProvider · Object

Information about the provider who oversaw the rendering provider and the care reported in this service line. Include this object when the supervising provider is different than the one listed in the supervising object for the entire claim.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

commercialNumber · claimInformation.serviceLines[].supervisingProvider.commercialNumber · String

The provider's commercial number.

firstName · claimInformation.serviceLines[].supervisingProvider.firstName · String

The provider's first name.

lastName · claimInformation.serviceLines[].supervisingProvider.lastName · String

The provider's last name.

locationNumber · claimInformation.serviceLines[].supervisingProvider.locationNumber · String

The provider's location number.

middleName · claimInformation.serviceLines[].supervisingProvider.middleName · String

The provider's middle name or initial.

npi · claimInformation.serviceLines[].supervisingProvider.npi · String Regex pattern: ^\d{10}$

The individual National Provider Identifier (NPI) assigned to the provider.

organizationName · claimInformation.serviceLines[].supervisingProvider.organizationName · String

The provider's business name.

providerUpinNumber · claimInformation.serviceLines[].supervisingProvider.providerUpinNumber · String

Deprecated; do not use.

stateLicenseNumber · claimInformation.serviceLines[].supervisingProvider.stateLicenseNumber · String

The provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · claimInformation.serviceLines[].supervisingProvider.suffix · String

The provider's name suffix, such as Jr. or III.

taxonomyCode · claimInformation.serviceLines[].supervisingProvider.taxonomyCode · String Deprecated Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.

teethInformation · claimInformation.serviceLines[].teethInformation · Array of Objects

Identify a tooth by its number and the surfaces involved in the service.

toothCode · claimInformation.serviceLines[].teethInformation[].toothCode · String Required

An American Dental Association CDT Code for the procedures performed on a specific tooth. You can only use this object to report individual teeth. You can't use it to report areas of the oral cavity, such as quadrants or sextants. Areas of the oral cavity are reported in the claimInformation.serviceLines.dentalService.oralCavityDesignation property. You can only include multiples of this object when claimInformation.serviceLines.dentalService.procedureCount is equal to 1. When applicable, you can include this object up to 32 times within a single service line.

toothSurfaceCodes · claimInformation.serviceLines[].teethInformation[].toothSurfaceCodes · Array of Strings Items: 1 - 5

Code identifying the area of the tooth that was treated. Can be set to B - Buccal, D- Distal, F- Facial, I- Incisal, L - Lingual, M - Mesial, or O Occlusal.

Possible values

B

D

F

I

L

signatureIndicator · claimInformation.signatureIndicator · String Required

Indicates whether the provider's signature is on file. Can be set to N - No or Y - Yes.

Possible values

N

Y

specialProgramCode · claimInformation.specialProgramCode · String

Code indicating the Special Program under which the services rendered to the patient were performed. Used for Medicaid claims only. Can be set to 01 - Early & Periodic Screening, Diagnosis and Treatment (EPSDT) or Child Assessment Program (CHAP), 02 - Physically Handicapped Children's Program, 03 - Special Federal Funding, or 05 - Disability. Codes 02, 03, and 05 are used for Medicaid claims only.

Possible values

01

02

03

05

toothStatus · claimInformation.toothStatus · Array of Objects

The status of the teeth involved in the service. Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. You can include up to 35 objects in this array.

toothNumber · claimInformation.toothStatus[].toothNumber · String Required

The tooth number according to the American Dental Association tooth designation system.

toothStatusCode · claimInformation.toothStatus[].toothStatusCode · String Required

Can be set to E - To Be Extracted, M - Missing.

Possible values

E

M

dependent · Object

Dependent who received the medical care associated with the claim. Note that if the dependent has their own member ID for the health plan, you should include the dependent's information in the subscriber object instead. To check whether a dependent has a member ID, submit an Eligibility Check to the payer. The payer returns the dependent's member ID in the dependents.memberId property in the response, if present.

address · dependent.address · Object

The dependent's address. Every claim must include address information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object. The state and postalCode properties are also required for all United States and Canadian addresses.

• The address must be the patient's correct address at the time of service. Don't use placeholder values to complete unknown address information. Use of outdated or placeholder values could cause the payer to reject, deny, or delay the claim due to suspected fraud.
• If you don't know the patient's address, you should first submit a Real-Time Eligibility Check for the patient and then copy the patient's address from either the subscriber or dependent object in the response.
• If the patient doesn't have a current address, you can populate the address1 property with UNKNOWN and populate the city, state, and zip code with appropriate values based on your discretion. However, some payers may have explicit rules for how to handle this situation, so you should check the payer's specific requirements before using this approach.

address1 · dependent.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · dependent.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · dependent.address.city · String Required

The city name.

countryCode · dependent.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · dependent.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · dependent.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · dependent.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

dateOfBirth · dependent.dateOfBirth · String Required Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The patient's date of birth

firstName · dependent.firstName · String Required

The patient's first name.

gender · dependent.gender · String Required

Code indiciating the patient's gender. Can be set to F - Female, M - Male, or U - Unknown.

Some payers may reject the claim if the patient's gender doesn't match the gender they have recorded in their member records. If the gender isn't known or the patient declines to answer, use U or perform an eligibility check to determine the gender according to the payer's records.

Possible values

M

F

U

lastName · dependent.lastName · String Required

The patient's last name. Don't include the patient's name suffix, such as Jr. or III. Use the designated suffix property instead.

memberId · dependent.memberId · String

The patient's identification number. Only used in Property and Casualty claims.

middleName · dependent.middleName · String

The patient's middle name or initial.

relationshipToSubscriberCode · dependent.relationshipToSubscriberCode · String Required

Identifies the relationship of the patient to the subscriber. Can be set to 01 - Spouse, 19 - Child, 20 - Employee, 21 - Unknown, 39 - Organ Donor, 40 - Cadaver Donor, 53 - Life Partner, or G8 - Other Relationship.

Possible values

01

19

20

21

39

ssn · dependent.ssn · String Regex pattern: ^\d{9}$

The patient's Social Security Number. Only used for Property and Casualty claims.

suffix · dependent.suffix · String

The patient's name suffix, such as Jr. or III. Only include the patient's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

payToAddress · Object

Use when the address for payment is different than that of the billing provider for this claim.

This is also where you can provide the billing provider's mailing address when it's a PO Box, lockbox, or other non-physical address. The billing.address object must always contain a physical practice location where care is delivered.

address1 · payToAddress.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · payToAddress.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · payToAddress.city · String Required

The city name.

countryCode · payToAddress.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · payToAddress.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · payToAddress.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · payToAddress.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

payToPlan · Object

Use for subrogation payment requests. If you include this information, you must also set the claimInformation.otherSubscriberInformation.payerPaidAmount to the amount the payer (for example, Medicaid) actually paid.

address · payToPlan.address · Object Required

The address of the pay-to-plan organization.

address1 · payToPlan.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · payToPlan.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · payToPlan.address.city · String Required

The city name.

countryCode · payToPlan.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · payToPlan.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · payToPlan.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · payToPlan.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

organizationName · payToPlan.organizationName · String Required

The last name of the individual, or the business name of the pay-to-plan organization.

primaryIdentifier · payToPlan.primaryIdentifier · String Required

The identifier you specified in primaryIdentifierTypeCode.

primaryIdentifierTypeCode · payToPlan.primaryIdentifierTypeCode · String Required

Code identifying the type of identifier. Can be set to PI - Payor Identification or XV - Centers for Medicare/Medicaid Services PlanID. Use code value XV when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

Possible values

PI

XV

secondaryIdentifier · payToPlan.secondaryIdentifier · String

The secondary identifier you specified in secondaryIdentifierTypeCode.

secondaryIdentifierTypeCode · payToPlan.secondaryIdentifierTypeCode · String

Code identifying the type of secondary identifier. Can be set to 2U - Payer Identification Number, FY - Claim Office Number, or NF - National Association of Insurance Commissioners. You should only set this to 2U when you set the primaryIdentifierTypeCode to XV.

Possible values

2U

FY

NF

taxIdentificationNumber · payToPlan.taxIdentificationNumber · String Required Length: 9

The Employer Identification Number (EIN). This must be a string of exactly nine numbers with no separators.

payerAddress · Object

The payer's address. Some payers use this for internal routing. Only provide this address if the payer explicitly requires it.

address1 · payerAddress.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · payerAddress.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · payerAddress.city · String Required

The city name.

countryCode · payerAddress.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · payerAddress.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · payerAddress.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · payerAddress.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

receiver · Object Required

The entity responsible for the payment of the claim, such as an insurance company or government agency.

organizationName · receiver.organizationName · String Required Min length: 1

The business name of the payer receiving the claim, such as Aetna or Cigna.

referring · Object

Information about the provider who directed the patient to the rendering provider for care. For example, a primary care physician may refer patients to a specialist. Use when the referring provider applies to the entire claim, not just a specific service line.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

address · referring.address · Object Deprecated

address1 · referring.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · referring.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · referring.address.city · String Required

The city name.

countryCode · referring.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · referring.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · referring.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · referring.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

commercialNumber · referring.commercialNumber · String

The provider's commercial number.

contactInformation · referring.contactInformation · Object Deprecated

You must include at least one communication method (phone, fax, or email) in this object.

email · referring.contactInformation.email · String

The email address.

faxNumber · referring.contactInformation.faxNumber · String

The fax number.

name · referring.contactInformation.name · String

The full name of the person or office.

phoneExtension · referring.contactInformation.phoneExtension · String

The phone extension, if applicable.

phoneNumber · referring.contactInformation.phoneNumber · String

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.

firstName · referring.firstName · String

The provider's first name.

lastName · referring.lastName · String

The provider's last name.

middleName · referring.middleName · String

The provider's middle name or initial.

npi · referring.npi · String Regex pattern: ^\d{10}$

The individual National Provider Identifier (NPI) assigned to the provider.

organizationName · referring.organizationName · String

The provider's business name.

providerType · referring.providerType · String Deprecated

This field is now automatically populated and it only remains for backwards compatibility.

providerUpinNumber · referring.providerUpinNumber · String Deprecated

Deprecated; do not use.

stateLicenseNumber · referring.stateLicenseNumber · String

The provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · referring.suffix · String

The provider's name suffix, such as Jr. or III.

taxonomyCode · referring.taxonomyCode · String Deprecated Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

rendering · Object

Information about the person or company (laboratory or other facility) who rendered the care. Use this object for all types of rendering providers including laboratories. When a substitute provider (locum tenens) was used, enter that provider's information here.

• Use when the provider applies to the entire claim or to at least one service line. For example, if a claim had two service lines with two different rendering providers, you would include the provider for the first service line here and leave the claimInformation.serviceLines.renderingProvider object for that service line blank. Then, you would specify the second provider in the appropriate service line's claimInformation.serviceLines.renderingProvider object.
• You can omit this object when the rendering provider is the same as the billing provider. In that case, you would include the provider's information in the billing object and leave this object blank.

address · rendering.address · Object Deprecated

address1 · rendering.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · rendering.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · rendering.address.city · String Required

The city name.

countryCode · rendering.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · rendering.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · rendering.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · rendering.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

commercialNumber · rendering.commercialNumber · String

The provider's commercial number.

contactInformation · rendering.contactInformation · Object Deprecated

You must include at least one communication method (phone, fax, or email) in this object.

email · rendering.contactInformation.email · String

The email address.

faxNumber · rendering.contactInformation.faxNumber · String

The fax number.

name · rendering.contactInformation.name · String

The full name of the person or office.

phoneExtension · rendering.contactInformation.phoneExtension · String

The phone extension, if applicable.

phoneNumber · rendering.contactInformation.phoneNumber · String

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.

firstName · rendering.firstName · String

The provider's first name, if the provider is an individual.

lastName · rendering.lastName · String

The provider's last name, if the provider is an individual. You must include either the lastName or organizationName property in this object.

locationNumber · rendering.locationNumber · String

The provider's location number.

middleName · rendering.middleName · String

The provider's middle name or initial, if the provider is an individual.

npi · rendering.npi · String Regex pattern: ^\d{10}$

The National Provider Identifier (NPI) assigned to the provider.

organizationName · rendering.organizationName · String

The provider's business name, if the provider is an organization. You must include either the lastName or organizationName property in this object.

providerType · rendering.providerType · String Deprecated

This field is now automatically populated and it only remains for backwards compatibility.

providerUpinNumber · rendering.providerUpinNumber · String Deprecated

Deprecated; do not use.

stateLicenseNumber · rendering.stateLicenseNumber · String

The provider's state license number. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · rendering.suffix · String

The provider's name suffix, such as Jr. or III.

taxonomyCode · rendering.taxonomyCode · String Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

Code from the National Uniform Claims Committee Health Care Provider Taxonomy Code Set. This identifies the provider's type and/or area of specialty.

submitter · Object Required

The entity submitting the healthcare claim. This can be either an individual or an organization, such as a doctor, hospital, or insurance company. You must submit at least organizationName or lastName properties and the contactInformation object. If you don't supply the submitterIdentification property, Stedi uses the value from billing.npi in the request.

contactInformation · submitter.contactInformation · Object Required

Contact information for the person or office handling administrative communications regarding the claim. You can include a maximum of two objects in this array.

email · submitter.contactInformation.email · String

The email address.

faxNumber · submitter.contactInformation.faxNumber · String

The fax number.

name · submitter.contactInformation.name · String

The full name of the person or office.

phoneExtension · submitter.contactInformation.phoneExtension · String

The phone extension, if applicable.

phoneNumber · submitter.contactInformation.phoneNumber · String

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.

firstName · submitter.firstName · String Length: 1 - 35

The first name of the individual submitting the claim.

lastName · submitter.lastName · String Length: 1 - 60

The last name of the individual submitting the claim.

middleName · submitter.middleName · String Length: 1 - 25

The middle name or initial of the individual submitting the claim.

organizationName · submitter.organizationName · String Length: 1 - 60

The business name of the organization submitting the claim.

submitterIdentification · submitter.submitterIdentification · String Length: 2 - 80

The submitter's Electronic Transmitter Identification Number (ETIN), as assigned by the payer. For some payers, this may be the same as the submitter's NPI or TIN, but it can also be another unique identifier. Payers can refer to this identifier as the Provider Number, Submitter ID, Submitter Identifier, Submitter Primary Number, Sender Code, Certified Contracted Provider ID, and other names.

If you don't provide this property, Stedi uses the billing provider's NPI from billing.npi property.

subscriber · Object Required

The person or entity who is the primary policyholder for the health plan or a dependent with their own member ID.

• When a dependent has a unique, payer-assigned member ID, treat them as the subscriber for the claim submission - include their information here and omit the dependent object from the request. Note that the subscriber can be an individual or a business entity. Stedi treats the subscriber as an individual when the request doesn't contain a value for the subscriber.organizationName property.
• You must set the dateOfBirth and gender properties when the subscriber is the patient. Stedi determines that the subscriber is the patient when the dependent object is not included in the request.
• If either dateOfBirth or gender is set, you must include both properties. You can either include both properties or neither within a single request.

address · subscriber.address · Object

The subscriber's address. Every claim must include address information in either the subscriber (when the patient is the subscriber) or dependent (when the patient is a dependent) object. You must include at least the address1 and city properties in this object. The state and postalCode properties are also required for all United States and Canadian addresses.

• The address must be the patient's correct address at the time of service. Don't use placeholder values to complete unknown address information. Use of outdated or placeholder values could cause the payer to reject, deny, or delay the claim due to suspected fraud.
• If you don't know the patient's address, you should first submit a Real-Time Eligibility Check for the patient and then copy the patient's address from either the subscriber or dependent object in the response.
• If the patient doesn't have a current address, you can populate the address1 property with UNKNOWN and populate the city, state, and zip code with appropriate values based on your discretion. However, some payers may have explicit rules for how to handle this situation, so you should check the payer's specific requirements before using this approach.

address1 · subscriber.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · subscriber.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · subscriber.address.city · String Required

The city name.

countryCode · subscriber.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · subscriber.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · subscriber.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · subscriber.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

dateOfBirth · subscriber.dateOfBirth · String Regex pattern: ^\d{4}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$

The subscriber's date of birth. This property is required if the subscriber is an individual.

firstName · subscriber.firstName · String

The subscriber's first name. This property is recommended when the subscriber is an individual. Some payers reject requests without the firstName property.

gender · subscriber.gender · String

Identifies the subscriber's gender. This property is required when the subscriber is the patient. Can be set to F - Female, M - Male, or U - Unknown.

Some payers may reject the claim if the patient's gender doesn't match the gender they have recorded in their member records. If the gender isn't known or the patient declines to answer, use U or perform an eligibility check to determine the gender according to the payer's records.

Possible values

M

F

U

groupNumber · subscriber.groupNumber · String

The subscriber's health plan group number.

• Provide this property OR the policyNumber, not both.
• Provide this property OR the subscriberGroupName, not both. If this property is set, Stedi ignores the subscriberGroupName property.

insuranceTypeCode · subscriber.insuranceTypeCode · String

Identifies the type of insurance policy within a specific insurance program. This property is required when sending claims to Medicare and Medicare is not the primary payer (paymentResponsibilityLevelCode is not set to P). Otherwise, don't include this property in the claim.

Visit Claims code lists for a complete list of insurance type codes.

Possible values

12

13

14

15

16

lastName · subscriber.lastName · String

The subscriber's last name. This property is required if the subscriber is an individual.

Don't include the subscriber's name suffix, such as Jr. or III. Use the designated suffix property instead.

memberId · subscriber.memberId · String Length: 2 - 80

The member ID for the subscriber's insurance policy. This property is required if the subscriber is an individual.

middleName · subscriber.middleName · String

The subscriber's middle name or initial.

organizationName · subscriber.organizationName · String

The business name of the entity submitting the claim. When the subscriber is an organization, you should identify the patient in the dependent object.

paymentResponsibilityLevelCode · subscriber.paymentResponsibilityLevelCode · String

Code identifying the payer's level of responsibility for paying this claim. Visit Claims code lists for a complete list of possible codes.

• Stedi sets this property to P - Primary by default. You only need to include it when you need to submit codes other than P. This can happen when the patient has multiple insurance policies. For example, if a patient is covered by both Medicare and an employer-sponsored commercial plan, you could bill the commercial plan first as P and then bill the Medicare payer second as S.
• Either this property or otherSubscriberInformation.paymentResponsibilityLevelCode must be set to P to indicate the primary insurance payer. Stedi rejects claims - including secondary and tertiary claims - that don't include information for the primary payer.

Possible values

A

B

C

D

E

policyNumber · subscriber.policyNumber · String

The subscriber's health plan policy number. You should provide either this property OR the groupNumber, not both.

ssn · subscriber.ssn · String Regex pattern: ^\d{9}$

The subscriber's Social Security Number.

subscriberGroupName · subscriber.subscriberGroupName · String

The name of the subscriber's health plan. For example, Cigna or Blue Cross Blue Shield.

Provide either this property OR the groupNumber, not both. If groupNumber is set, Stedi ignores this value and uses the value in groupNumber.

suffix · subscriber.suffix · String

The suffix of the subscriber's name, such as Jr. or Sr. Only include the subscriber's personal name suffix - don't include professional or academic titles, such as M.D. or MBA.

supervising · Object

The entity responsible for overseeing the rendering provider and the care reported in this claim. Applies when the rendering provider is supervised by a physician. Use when the provider applies to the entire claim, not just a specific service line.

This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

address · supervising.address · Object Deprecated

address1 · supervising.address.address1 · String Required

The first line of the street address. This typically contains the building number and street name.

address2 · supervising.address.address2 · String

The second line of the street address. This typically contains the apartment or suite number.

city · supervising.address.city · String Required

The city name.

countryCode · supervising.address.countryCode · String

Use the alpha-2 country codes from Part 1 of ISO 3166.

countrySubDivisionCode · supervising.address.countrySubDivisionCode · String

Use the country subdivision codes from Part 2 of ISO 3166.

postalCode · supervising.address.postalCode · String

The postal zone or zip code. Exclude punctuation and spaces.

state · supervising.address.state · String

The state or province code. Only required when the city is in the Unites States and Canada.

commercialNumber · supervising.commercialNumber · String

The commercial number of the supervising provider.

contactInformation · supervising.contactInformation · Object Deprecated

You must include at least one communication method (phone, fax, or email) in this object.

email · supervising.contactInformation.email · String

The email address.

faxNumber · supervising.contactInformation.faxNumber · String

The fax number.

name · supervising.contactInformation.name · String

The full name of the person or office.

phoneExtension · supervising.contactInformation.phoneExtension · String

The phone extension, if applicable.

phoneNumber · supervising.contactInformation.phoneNumber · String

The phone number, formatted as AAABBBCCCC, where AAA represents the area code, BBB is the telephone number prefix, and CCCC is the telephone number. The phone number should only include the digits 0 to 9. Don't include separators, such as dashes, and don't include long distance access numbers, such as 1. For example, you would format the phone number 123-456-7890 as 1234567890.

employerId · supervising.employerId · String Deprecated

firstName · supervising.firstName · String

The first name of the supervising provider.

lastName · supervising.lastName · String

The last name of the supervising provider.

locationNumber · supervising.locationNumber · String

The location number of the supervising provider.

middleName · supervising.middleName · String

The middle name or initial of the supervising provider.

npi · supervising.npi · String Regex pattern: ^\d{10}$

The individual National Provider Identifier (NPI) assigned to the supervising provider.

organizationName · supervising.organizationName · String

The supervising provider's business name, when the provider is not an individual.

providerType · supervising.providerType · String Deprecated

This field is now automatically populated and it only remains for backwards compatibility.

providerUpinNumber · supervising.providerUpinNumber · String Deprecated

Deprecated; do not use.

ssn · supervising.ssn · String Deprecated Regex pattern: ^\d{9}$

Social Security Number without spaces or punctuation (9 digits)

stateLicenseNumber · supervising.stateLicenseNumber · String

The state license number of the supervising provider. This is assigned directly by a payer in order to identify the provider in their system. This is not commonly used.

suffix · supervising.suffix · String

The suffix of the supervising provider's name, such as Jr. or III.

taxonomyCode · supervising.taxonomyCode · String Deprecated Regex pattern: ^[A-Za-z0-9]{10}$ Length: 10

tradingPartnerName · String

This is the payer's business name, like Cigna or Aetna.

tradingPartnerServiceId · String Required

This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.

usageIndicator · String

Whether you want to send a test or production claim. This property also allows you to filter claims in the Stedi portal by production or test data. By default, this property is set to P for production data. Use T to designate a claim as test data.

Response

application/json

DentalClaimsSubmission 200 response

claimReference · Object

Information about the claim.

claimType · claimReference.claimType · String Deprecated

This shape is deprecated: Currently not used.

correlationId · claimReference.correlationId · String

An identifier Stedi assigns to the claim.

customerClaimNumber · claimReference.customerClaimNumber · String

A tracking number that Stedi assigns to the claim.

formatVersion · claimReference.formatVersion · String

The X12 EDI version Stedi used to generate the claim for the payer. This is always 5010.

patientControlNumber · claimReference.patientControlNumber · String

The patientControlNumber from the original request, if supplied. This is a unique identifier that you assign to the claim so you can track the claim and correlate it with responses from the payer.

payerID · claimReference.payerID · String Deprecated

This shape is deprecated: Please use payerId.

payerId · claimReference.payerId · String

The payer's ID. This is the same as the tradingPartnerServiceId.

rhclaimNumber · claimReference.rhclaimNumber · String

A tracking number Stedi assigns to the claim. This is the same as the correlationId.

serviceLines · claimReference.serviceLines · Array of Objects

Contains a unique identifier for each service line, listed in the order the service lines were included in the claim. You can use these identifiers to correlate payer responses to specific service lines.

lineItemControlNumber · claimReference.serviceLines[].lineItemControlNumber · String

A unique identifier for the service line, matching the value provided for the claimInformation.serviceLines.providerControlNumber property in the claim submission. If you didn't provide a value for providerControlNumber, this property contains a randomly generated a ULID for the service line.

submitterId · claimReference.submitterId · String

Stedi's ID for the entity that submitted the claim.

timeOfResponse · claimReference.timeOfResponse · String

A timestamp for Stedi's response to the claim submission.

controlNumber · String

An identifier for the transaction.

editResponses · Array of Objects

Currently not used.

allowOverride · editResponses[].allowOverride · String

badData · editResponses[].badData · String

claimCorePath · editResponses[].claimCorePath · String

editActivity · editResponses[].editActivity · String

editName · editResponses[].editName · String

element · editResponses[].element · String

errorDescription · editResponses[].errorDescription · String

fieldIndex · editResponses[].fieldIndex · String

loop · editResponses[].loop · String

phaseID · editResponses[].phaseID · String

qualifierCode · editResponses[].qualifierCode · String

referenceID · editResponses[].referenceID · String

segment · editResponses[].segment · String

editStatus · String Deprecated

This shape is deprecated: Currently not used.

errors · Array of Objects

Errors resulting from claim edits. You must review and fix these errors before resubmitting.

code · errors[].code · String

The error code.

description · errors[].description · String

The description of the error code.

field · errors[].field · String

The field related to the error.

followupAction · errors[].followupAction · String

Recommended followup actions to correct the error.

location · errors[].location · String

Where the error is located in the original request.

value · errors[].value · String

The value for the data causing the error.

failure · Object

Currently not used.

code · failure.code · String

description · failure.description · String

httpStatusCode · String

A 200 response indicates that Stedi successfully generated the X12 EDI claim format required by the payer. It does not indicate whether the payer has accepted the claim - the payer will respond later with a 277CA containing this information. Learn more about 277CAs. A 400 response indicates one or more problems with the claim data in the request. Examples include missing required fields, invalid values, or incorrect data types. The response includes a message describing the problem.

Possible values

200 OK

400 BAD_REQUEST

meta · Object

Metadata from Stedi about the request.

applicationMode · meta.applicationMode · String

Indicates where this request can be found for support.

billerId · meta.billerId · String

The biller ID assigned to this request.

senderId · meta.senderId · String

The sender ID assigned to this request.

submitterId · meta.submitterId · String

The submitter ID assigned to this request.

traceId · meta.traceId · String

The file execution ID, a unique identifier assigned to the processed file within the Stedi platform.

payer · Object

Information about the payer for the submitted claim.

payerID · payer.payerID · String Deprecated

This shape is deprecated: Please use payerId.

payerId · payer.payerId · String

The payer's ID. This is the same as the tradingPartnerServiceId.

payerName · payer.payerName · String

The payer's business name, such as Aetna or Cigna.

status · String

The status of the claim submission.

tradingPartnerServiceId · String

An ID for the payer you identified in the original claim. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.

warnings · Array of Objects

A list of warnings. Currently not used.

code · warnings[].code · String

A machine-readable code indicating the type of problem.

description · warnings[].description · String

A human-readable description of the problem.

cURL

curl --request POST \
  --url "https://healthcare.us.stedi.com/2024-04-01/dental-claims/submission" \
  --header "Authorization: <api_key>" \
  --header "Content-Type: application/json" \
  --data '{
    "billing": {
      "address": {
        "address1": "ABA Inc 123 Some St",
        "city": "Denver",
        "postalCode": "802383000",
        "state": "CO"
      },
      "contactInformation": {
        "name": "ABA Inc",
        "phoneNumber": "3134893157"
      },
      "employerId": "123456789",
      "npi": "1999999992",
      "organizationName": "ABA Inc",
      "providerType": "BillingProvider",
      "taxonomyCode": "106S00000X"
    },
    "claimInformation": {
      "benefitsAssignmentCertificationIndicator": "Y",
      "claimChargeAmount": "832.00",
      "claimFilingCode": "FI",
      "claimFrequencyCode": "1",
      "claimSupplementalInformation": {
        "priorAuthorizationNumber": "20231010012345678"
      },
      "healthCareCodeInformation": [
        {
          "diagnosisCode": "K08101",
          "diagnosisTypeCode": "ABK"
        }
      ],
      "patientControlNumber": "<YOUR-CLAIM-ID>",
      "placeOfServiceCode": "12",
      "planParticipationCode": "A",
      "releaseInformationCode": "Y",
      "serviceFacilityLocation": {
        "address": {
          "address1": "ABA Inc 123 Some St",
          "city": "Denver",
          "postalCode": "802383100",
          "state": "CO"
        },
        "npi": "1999999992",
        "organizationName": "ABA Inc",
        "phoneNumber": "3131234567"
      },
      "serviceLines": [
        {
          "dentalService": {
            "compositeDiagnosisCodePointers": {
              "diagnosisCodePointers": [
                "1"
              ]
            },
            "lineItemChargeAmount": "832.00",
            "oralCavityDesignation": [
              "1",
              "2"
            ],
            "placeOfServiceCode": "12",
            "procedureCode": "D7140",
            "procedureCount": 2,
            "prosthesisCrownOrInlayCode": "I"
          },
          "providerControlNumber": "a0UDo000000dd2dMAA",
          "renderingProvider": {
            "firstName": "Jane",
            "lastName": "Doe",
            "npi": "1999999992",
            "taxonomyCode": "122300000X"
          },
          "serviceDate": "20230428",
          "teethInformation": [
            {
              "toothCode": "3",
              "toothSurfaceCodes": [
                "M",
                "O"
              ]
            }
          ]
        }
      ],
      "signatureIndicator": "Y",
      "toothStatus": [
        {
          "toothNumber": "3",
          "toothStatusCode": "E"
        }
      ]
    },
    "payerAddress": {
      "address1": "PO Box 7000",
      "city": "Camden",
      "postalCode": "29000",
      "state": "SC"
    },
    "receiver": {
      "organizationName": "United HealthCare Dental"
    },
    "rendering": {
      "firstName": "Jane",
      "lastName": "Doe",
      "npi": "1999999992",
      "providerType": "RenderingProvider",
      "taxonomyCode": "106S00000X"
    },
    "submitter": {
      "contactInformation": {
        "name": "BILLING DEPARTMENT",
        "phoneNumber": "3131234567"
      },
      "organizationName": "ABA Inc",
      "submitterIdentification": "<YOUR-SUBMITTER-ID"
    },
    "subscriber": {
      "address": {
        "address1": "1234 Some St",
        "city": "Buckeye",
        "postalCode": "85326",
        "state": "AZ"
      },
      "dateOfBirth": "20180615",
      "firstName": "John",
      "gender": "F",
      "groupNumber": "1234567890",
      "lastName": "Doe",
      "memberId": "123412345",
      "paymentResponsibilityLevelCode": "P"
    },
    "tradingPartnerName": "United HealthCare Dental",
    "tradingPartnerServiceId": "52133",
    "usageIndicator": "T"
  }'

JavaScript

const body = JSON.stringify({
  "billing": {
    "address": {
      "address1": "ABA Inc 123 Some St",
      "city": "Denver",
      "postalCode": "802383000",
      "state": "CO"
    },
    "contactInformation": {
      "name": "ABA Inc",
      "phoneNumber": "3134893157"
    },
    "employerId": "123456789",
    "npi": "1999999992",
    "organizationName": "ABA Inc",
    "providerType": "BillingProvider",
    "taxonomyCode": "106S00000X"
  },
  "claimInformation": {
    "benefitsAssignmentCertificationIndicator": "Y",
    "claimChargeAmount": "832.00",
    "claimFilingCode": "FI",
    "claimFrequencyCode": "1",
    "claimSupplementalInformation": {
      "priorAuthorizationNumber": "20231010012345678"
    },
    "healthCareCodeInformation": [
      {
        "diagnosisCode": "K08101",
        "diagnosisTypeCode": "ABK"
      }
    ],
    "patientControlNumber": "<YOUR-CLAIM-ID>",
    "placeOfServiceCode": "12",
    "planParticipationCode": "A",
    "releaseInformationCode": "Y",
    "serviceFacilityLocation": {
      "address": {
        "address1": "ABA Inc 123 Some St",
        "city": "Denver",
        "postalCode": "802383100",
        "state": "CO"
      },
      "npi": "1999999992",
      "organizationName": "ABA Inc",
      "phoneNumber": "3131234567"
    },
    "serviceLines": [
      {
        "dentalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              "1"
            ]
          },
          "lineItemChargeAmount": "832.00",
          "oralCavityDesignation": [
            "1",
            "2"
          ],
          "placeOfServiceCode": "12",
          "procedureCode": "D7140",
          "procedureCount": 2,
          "prosthesisCrownOrInlayCode": "I"
        },
        "providerControlNumber": "a0UDo000000dd2dMAA",
        "renderingProvider": {
          "firstName": "Jane",
          "lastName": "Doe",
          "npi": "1999999992",
          "taxonomyCode": "122300000X"
        },
        "serviceDate": "20230428",
        "teethInformation": [
          {
            "toothCode": "3",
            "toothSurfaceCodes": [
              "M",
              "O"
            ]
          }
        ]
      }
    ],
    "signatureIndicator": "Y",
    "toothStatus": [
      {
        "toothNumber": "3",
        "toothStatusCode": "E"
      }
    ]
  },
  "payerAddress": {
    "address1": "PO Box 7000",
    "city": "Camden",
    "postalCode": "29000",
    "state": "SC"
  },
  "receiver": {
    "organizationName": "United HealthCare Dental"
  },
  "rendering": {
    "firstName": "Jane",
    "lastName": "Doe",
    "npi": "1999999992",
    "providerType": "RenderingProvider",
    "taxonomyCode": "106S00000X"
  },
  "submitter": {
    "contactInformation": {
      "name": "BILLING DEPARTMENT",
      "phoneNumber": "3131234567"
    },
    "organizationName": "ABA Inc",
    "submitterIdentification": "<YOUR-SUBMITTER-ID"
  },
  "subscriber": {
    "address": {
      "address1": "1234 Some St",
      "city": "Buckeye",
      "postalCode": "85326",
      "state": "AZ"
    },
    "dateOfBirth": "20180615",
    "firstName": "John",
    "gender": "F",
    "groupNumber": "1234567890",
    "lastName": "Doe",
    "memberId": "123412345",
    "paymentResponsibilityLevelCode": "P"
  },
  "tradingPartnerName": "United HealthCare Dental",
  "tradingPartnerServiceId": "52133",
  "usageIndicator": "T"
})

fetch("https://healthcare.us.stedi.com/2024-04-01/dental-claims/submission", {
  headers: {
    "Authorization": "<api_key>"
  },
  body
})

Go

package main

import (
  "fmt"
  "net/http"
  "io/ioutil"
  "strings"
)

func main() {
  url := "https://healthcare.us.stedi.com/2024-04-01/dental-claims/submission"
  body := strings.NewReader(`{
    "billing": {
      "address": {
        "address1": "ABA Inc 123 Some St",
        "city": "Denver",
        "postalCode": "802383000",
        "state": "CO"
      },
      "contactInformation": {
        "name": "ABA Inc",
        "phoneNumber": "3134893157"
      },
      "employerId": "123456789",
      "npi": "1999999992",
      "organizationName": "ABA Inc",
      "providerType": "BillingProvider",
      "taxonomyCode": "106S00000X"
    },
    "claimInformation": {
      "benefitsAssignmentCertificationIndicator": "Y",
      "claimChargeAmount": "832.00",
      "claimFilingCode": "FI",
      "claimFrequencyCode": "1",
      "claimSupplementalInformation": {
        "priorAuthorizationNumber": "20231010012345678"
      },
      "healthCareCodeInformation": [
        {
          "diagnosisCode": "K08101",
          "diagnosisTypeCode": "ABK"
        }
      ],
      "patientControlNumber": "<YOUR-CLAIM-ID>",
      "placeOfServiceCode": "12",
      "planParticipationCode": "A",
      "releaseInformationCode": "Y",
      "serviceFacilityLocation": {
        "address": {
          "address1": "ABA Inc 123 Some St",
          "city": "Denver",
          "postalCode": "802383100",
          "state": "CO"
        },
        "npi": "1999999992",
        "organizationName": "ABA Inc",
        "phoneNumber": "3131234567"
      },
      "serviceLines": [
        {
          "dentalService": {
            "compositeDiagnosisCodePointers": {
              "diagnosisCodePointers": [
                "1"
              ]
            },
            "lineItemChargeAmount": "832.00",
            "oralCavityDesignation": [
              "1",
              "2"
            ],
            "placeOfServiceCode": "12",
            "procedureCode": "D7140",
            "procedureCount": 2,
            "prosthesisCrownOrInlayCode": "I"
          },
          "providerControlNumber": "a0UDo000000dd2dMAA",
          "renderingProvider": {
            "firstName": "Jane",
            "lastName": "Doe",
            "npi": "1999999992",
            "taxonomyCode": "122300000X"
          },
          "serviceDate": "20230428",
          "teethInformation": [
            {
              "toothCode": "3",
              "toothSurfaceCodes": [
                "M",
                "O"
              ]
            }
          ]
        }
      ],
      "signatureIndicator": "Y",
      "toothStatus": [
        {
          "toothNumber": "3",
          "toothStatusCode": "E"
        }
      ]
    },
    "payerAddress": {
      "address1": "PO Box 7000",
      "city": "Camden",
      "postalCode": "29000",
      "state": "SC"
    },
    "receiver": {
      "organizationName": "United HealthCare Dental"
    },
    "rendering": {
      "firstName": "Jane",
      "lastName": "Doe",
      "npi": "1999999992",
      "providerType": "RenderingProvider",
      "taxonomyCode": "106S00000X"
    },
    "submitter": {
      "contactInformation": {
        "name": "BILLING DEPARTMENT",
        "phoneNumber": "3131234567"
      },
      "organizationName": "ABA Inc",
      "submitterIdentification": "<YOUR-SUBMITTER-ID"
    },
    "subscriber": {
      "address": {
        "address1": "1234 Some St",
        "city": "Buckeye",
        "postalCode": "85326",
        "state": "AZ"
      },
      "dateOfBirth": "20180615",
      "firstName": "John",
      "gender": "F",
      "groupNumber": "1234567890",
      "lastName": "Doe",
      "memberId": "123412345",
      "paymentResponsibilityLevelCode": "P"
    },
    "tradingPartnerName": "United HealthCare Dental",
    "tradingPartnerServiceId": "52133",
    "usageIndicator": "T"
  }`)
  req, _ := http.NewRequest("POST", url, body)
  req.Header.Add("Authorization", "<api_key>")
  req.Header.Add("Content-Type", "application/json")
  res, _ := http.DefaultClient.Do(req)
  defer res.Body.Close()
  body, _ := ioutil.ReadAll(res.Body)

  fmt.Println(res)
  fmt.Println(string(body))
}

Python

import requests

url = "https://healthcare.us.stedi.com/2024-04-01/dental-claims/submission"
body = {
  "billing": {
    "address": {
      "address1": "ABA Inc 123 Some St",
      "city": "Denver",
      "postalCode": "802383000",
      "state": "CO"
    },
    "contactInformation": {
      "name": "ABA Inc",
      "phoneNumber": "3134893157"
    },
    "employerId": "123456789",
    "npi": "1999999992",
    "organizationName": "ABA Inc",
    "providerType": "BillingProvider",
    "taxonomyCode": "106S00000X"
  },
  "claimInformation": {
    "benefitsAssignmentCertificationIndicator": "Y",
    "claimChargeAmount": "832.00",
    "claimFilingCode": "FI",
    "claimFrequencyCode": "1",
    "claimSupplementalInformation": {
      "priorAuthorizationNumber": "20231010012345678"
    },
    "healthCareCodeInformation": [
      {
        "diagnosisCode": "K08101",
        "diagnosisTypeCode": "ABK"
      }
    ],
    "patientControlNumber": "<YOUR-CLAIM-ID>",
    "placeOfServiceCode": "12",
    "planParticipationCode": "A",
    "releaseInformationCode": "Y",
    "serviceFacilityLocation": {
      "address": {
        "address1": "ABA Inc 123 Some St",
        "city": "Denver",
        "postalCode": "802383100",
        "state": "CO"
      },
      "npi": "1999999992",
      "organizationName": "ABA Inc",
      "phoneNumber": "3131234567"
    },
    "serviceLines": [
      {
        "dentalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              "1"
            ]
          },
          "lineItemChargeAmount": "832.00",
          "oralCavityDesignation": [
            "1",
            "2"
          ],
          "placeOfServiceCode": "12",
          "procedureCode": "D7140",
          "procedureCount": 2,
          "prosthesisCrownOrInlayCode": "I"
        },
        "providerControlNumber": "a0UDo000000dd2dMAA",
        "renderingProvider": {
          "firstName": "Jane",
          "lastName": "Doe",
          "npi": "1999999992",
          "taxonomyCode": "122300000X"
        },
        "serviceDate": "20230428",
        "teethInformation": [
          {
            "toothCode": "3",
            "toothSurfaceCodes": [
              "M",
              "O"
            ]
          }
        ]
      }
    ],
    "signatureIndicator": "Y",
    "toothStatus": [
      {
        "toothNumber": "3",
        "toothStatusCode": "E"
      }
    ]
  },
  "payerAddress": {
    "address1": "PO Box 7000",
    "city": "Camden",
    "postalCode": "29000",
    "state": "SC"
  },
  "receiver": {
    "organizationName": "United HealthCare Dental"
  },
  "rendering": {
    "firstName": "Jane",
    "lastName": "Doe",
    "npi": "1999999992",
    "providerType": "RenderingProvider",
    "taxonomyCode": "106S00000X"
  },
  "submitter": {
    "contactInformation": {
      "name": "BILLING DEPARTMENT",
      "phoneNumber": "3131234567"
    },
    "organizationName": "ABA Inc",
    "submitterIdentification": "<YOUR-SUBMITTER-ID"
  },
  "subscriber": {
    "address": {
      "address1": "1234 Some St",
      "city": "Buckeye",
      "postalCode": "85326",
      "state": "AZ"
    },
    "dateOfBirth": "20180615",
    "firstName": "John",
    "gender": "F",
    "groupNumber": "1234567890",
    "lastName": "Doe",
    "memberId": "123412345",
    "paymentResponsibilityLevelCode": "P"
  },
  "tradingPartnerName": "United HealthCare Dental",
  "tradingPartnerServiceId": "52133",
  "usageIndicator": "T"
}
response = requests.request("POST", url, json = body, headers = {
  "Authorization": "<api_key>",
  "Content-Type": "application/json"
})

print(response.text)

Java

import java.net.URI;
import java.net.http.HttpClient;
import java.net.http.HttpRequest;
import java.net.http.HttpResponse;
import java.net.http.HttpResponse.BodyHandlers;
import java.time.Duration;
import java.net.http.HttpRequest.BodyPublishers;

var body = BodyPublishers.ofString("""{
  "billing": {
    "address": {
      "address1": "ABA Inc 123 Some St",
      "city": "Denver",
      "postalCode": "802383000",
      "state": "CO"
    },
    "contactInformation": {
      "name": "ABA Inc",
      "phoneNumber": "3134893157"
    },
    "employerId": "123456789",
    "npi": "1999999992",
    "organizationName": "ABA Inc",
    "providerType": "BillingProvider",
    "taxonomyCode": "106S00000X"
  },
  "claimInformation": {
    "benefitsAssignmentCertificationIndicator": "Y",
    "claimChargeAmount": "832.00",
    "claimFilingCode": "FI",
    "claimFrequencyCode": "1",
    "claimSupplementalInformation": {
      "priorAuthorizationNumber": "20231010012345678"
    },
    "healthCareCodeInformation": [
      {
        "diagnosisCode": "K08101",
        "diagnosisTypeCode": "ABK"
      }
    ],
    "patientControlNumber": "<YOUR-CLAIM-ID>",
    "placeOfServiceCode": "12",
    "planParticipationCode": "A",
    "releaseInformationCode": "Y",
    "serviceFacilityLocation": {
      "address": {
        "address1": "ABA Inc 123 Some St",
        "city": "Denver",
        "postalCode": "802383100",
        "state": "CO"
      },
      "npi": "1999999992",
      "organizationName": "ABA Inc",
      "phoneNumber": "3131234567"
    },
    "serviceLines": [
      {
        "dentalService": {
          "compositeDiagnosisCodePointers": {
            "diagnosisCodePointers": [
              "1"
            ]
          },
          "lineItemChargeAmount": "832.00",
          "oralCavityDesignation": [
            "1",
            "2"
          ],
          "placeOfServiceCode": "12",
          "procedureCode": "D7140",
          "procedureCount": 2,
          "prosthesisCrownOrInlayCode": "I"
        },
        "providerControlNumber": "a0UDo000000dd2dMAA",
        "renderingProvider": {
          "firstName": "Jane",
          "lastName": "Doe",
          "npi": "1999999992",
          "taxonomyCode": "122300000X"
        },
        "serviceDate": "20230428",
        "teethInformation": [
          {
            "toothCode": "3",
            "toothSurfaceCodes": [
              "M",
              "O"
            ]
          }
        ]
      }
    ],
    "signatureIndicator": "Y",
    "toothStatus": [
      {
        "toothNumber": "3",
        "toothStatusCode": "E"
      }
    ]
  },
  "payerAddress": {
    "address1": "PO Box 7000",
    "city": "Camden",
    "postalCode": "29000",
    "state": "SC"
  },
  "receiver": {
    "organizationName": "United HealthCare Dental"
  },
  "rendering": {
    "firstName": "Jane",
    "lastName": "Doe",
    "npi": "1999999992",
    "providerType": "RenderingProvider",
    "taxonomyCode": "106S00000X"
  },
  "submitter": {
    "contactInformation": {
      "name": "BILLING DEPARTMENT",
      "phoneNumber": "3131234567"
    },
    "organizationName": "ABA Inc",
    "submitterIdentification": "<YOUR-SUBMITTER-ID"
  },
  "subscriber": {
    "address": {
      "address1": "1234 Some St",
      "city": "Buckeye",
      "postalCode": "85326",
      "state": "AZ"
    },
    "dateOfBirth": "20180615",
    "firstName": "John",
    "gender": "F",
    "groupNumber": "1234567890",
    "lastName": "Doe",
    "memberId": "123412345",
    "paymentResponsibilityLevelCode": "P"
  },
  "tradingPartnerName": "United HealthCare Dental",
  "tradingPartnerServiceId": "52133",
  "usageIndicator": "T"
}""");
HttpClient client = HttpClient.newBuilder()
  .connectTimeout(Duration.ofSeconds(10))
  .build();

HttpRequest.Builder requestBuilder = HttpRequest.newBuilder()
  .uri(URI.create("https://healthcare.us.stedi.com/2024-04-01/dental-claims/submission"))
  .header("Content-Type", "application/json")
  .header("Authorization", "<api_key>")
  .POST(body)
  .build();

try {
  HttpResponse<String> response = client.send(requestBuilder.build(), BodyHandlers.ofString());
  System.out.println("Status code: " + response.statusCode());
  System.out.println("Response body: " + response.body());
} catch (Exception e) {
  e.printStackTrace();
}

200

{
  "claimReference": {
    "correlationId": "01JDQMX92Q1T561BH8NKX750TQ",
    "formatVersion": "5010",
    "patientControlNumber": "0U1LBRS4",
    "payerId": "52133",
    "rhclaimNumber": "01JDQMX92Q1T561BH8NKX750TQ",
    "serviceLines": [
      {
        "lineItemControlNumber": "a0UDo000000dd2dMAA"
      }
    ],
    "timeOfResponse": "2024-11-27T20:27:27.077Z"
  },
  "controlNumber": "1",
  "httpStatusCode": "200 OK",
  "meta": {
    "traceId": "9b491769-052e-4738-93d6-e0b5f6d83f53"
  },
  "payer": {
    "payerId": "52133",
    "payerName": "United HealthCare Dental"
  },
  "status": "SUCCESS",
  "tradingPartnerServiceId": "52133"
}

400

{
  "code": "string",
  "message": "string"
}

403

{
  "code": "string",
  "message": "string"
}

404

{
  "code": "string",
  "message": "string"
}

429

{
  "code": "string",
  "message": "string"
}

500

{
  "code": "string",
  "message": "string"
}

503

{
  "code": "string",
  "message": "string"
}

504

{
  "code": "string",
  "message": "string"
}