Contract/File Information - Dental

The Contract/File Information section displays information related to the services rendered to a patient. This information is required on claims when the information is known to impact the payer's adjudication process.

Contract Information

The Contract section is used to specify basic data about the contract or contract line item. This information is required when the submitter is contractually obligated to supply this information on post-adjudicated claims. The Contract fields are defined below:

Type CodeType Code

Code identifying a contract type. Options are:

01	Diagnosis Related Group (DRG)
02	Per Diem
03	Variable Per Diem
04	Flat
05	Capitated
06	Percent
09	Other

AmountAmount

Monetary amount of the contract.

Contract PercentageContract Percentage

The allowance or charge percent.

Terms Discount PercentageTerms Discount Percentage

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

Contract CodeContract Code

Reference information as defined for a particular transaction set or as specified by the Reference Identification Qualifier.

Version IdentifierVersion Identifier

Additional identifying number for the contract.

Notes: The Notes fields are defined below:

Note TextNote Text

A free-form description to clarify the related data elements and their content. Click the (+) icon to add up to five (5) additional notes.

File Information: The File Information section displays information about the file relating to the claim. The File Information fields are defined below:

Attachment Report Type CodeAttachment Report Type Code

Code indicating the title or contents of a document, report, or supporting item. Options are:

03	Report Justifying Treatment Beyond Utilization Guidelines
04	Drugs Administered
05	Treatment Diagnosis
06	Initial Assessment
07	Functional Goals
08	Plan of Treatment
09	Progress Report
10	Continued Treatment
11	Chemical Analysis
13	Certified Test Report
15	Justification for Admission
21	Recovery Plan
A3	Allergies/Sensitivities Document
A4	Autopsy Report
AM	Ambulance Certification
AS	Admission Summary
B2	Prescription
B3	Physician Order
B4	Referral Form
BR	Benchmark Testing Results
BS	Baseline
BT	Blanket Test Results
CB	Chiropractic Justification
CK	Consent Form(s)
CT	Certification
D2	Drug Profile Document
DA	Dental Models
DB	Durable Medical Equipment Prescription
DG	Diagnostic Report
DJ	Discharge Monitoring Report
DS	Discharge Summary
EB	Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer)
HC	Health Certificate
HR	Health Clinic Records
I5	Immunization Record
IR	State School Immunization Records
LA	Laboratory Results
M1	Medical Record Attachment
MT	Models
NN	Nursing Notes
OB	Operative Note
OC	Oxygen Content Averaging Report
OD	Orders and Treatments Document
OE	Objective Physical Examination (including vital signs)
OX	Oxygen Therapy Certification
OZ	Support Data for Claim
P4	Pathology Report
P5	Patient Medical History Document
PE	Parenteral or Enteral Certification
PN	Physical Therapy Notes
PO	Prosthetics or Orthotic Certification
PQ	Paramedical Results
PY	Physician's Report
PZ	Physical Therapy Certification
RB	Radiology Films
RR	Radiology Reports
RT	Report of Tests and Analysis Report
RX	Renewable Oxygen Content Averaging Report
SG	Symptoms Document
V5	Death Notification
XP	Photographs

Attachment Transmission CodeAttachment Transmission Code

Code defining timing, transmission method, or format by which reports are to be sent. Options are:

AA	Available on Request at Provider Site (this means the additional information is not being sent with the claim at this time; it is available to the payer at their request)
BM	By Mail
EL	Electronically Only (indicates the attachment is being transmitted in a separate X12 functional group)
EM	Email Transfer
FT	File Transfer
FX	By Fax

Attachment Control NumberAttachment Control Number

Code used to identify the attached electronic documentation. Required when the transmission code = BM, EL, EM, FT, or FX. If not required, do not send.

Add Attachment InfoAdd Attachment Info (button)

Click to add additional attachment information. Up to 10 iterations can be added.

Fixed Format Information

Fixed Format 1-2Fixed Format 1-2

Additional claim information. This data is in a fixed format agreed upon by the sender and receiver. Click (+) to add additional lines. Up to ten (10) lines may be added.