MN–ITS Help Text – 837D – Service Line

The table below describes the individual fields on the Services screens used for line item billing, line item coordination of benefits reporting, and reporting other providers for a specific service line. * The Field Name column identifies X12 loops and elements only for fields that display in the MN–ITS screens. Refer to the X12 HIPAA Companion Guides available through the WPC X12 Registry for additional instruction when submitting batch claims.

Select MN–ITS User Guides to obtain additional instruction for submitting claims for specific services using MN–ITS DDE.

Field Name*
(X12 Loop and element)

Valid Values

Character Length

Field Descriptions

Date of Service (From)
(Loop: 2400, DTP03)

MMDDCCYY

8
(numeric)

The date the service was completed

Date of Service (To)
(Loop: 2400, DTP03)

MMDDCCYY

8
(numeric)

Treatment completion date

Place of Service
(Loop: 2400, SV303)

Refer to the MN–ITS screen for values available

 

Identifies where the service/item was rendered

Procedure Code
(Loop: 2430, SV301-2)

 

5
(alphanumeric)

Code (CDT) identifying the service

Procedure Code Modifier(s)
(Loop: 2400, SV101-3, SV101-4, SV101-5, SV101-6)

 

2
(alphanumeric)

Code (HCPCS or CDT modifier) that clarifies or further identifies the service indicated in the procedure code field

Diagnosis Pointer(s)
(Loop: 2400, SV311-1, SV311-2, SV311-3, SV311-4)

Refer to the MN–ITS screen for values available

 

Indicates, in the order of importance, the diagnosis code(s) from the Claim Information screen that apply to this service

Default is V72.2 Dental Examination

Line Item Charge Amount
(Loop: 2400, SV302)

 

10
(numeric)

The usual and customary charge for the service performed

Service Unit Count
(Loop: 2400, SV306)

 

1-15
(numeric)

The quantity of units for the service

Other Payer

Other Payer Primary ID
(Loop: 2430, REF04-2)

Refer to the MN–ITS screen for values available

 

Identifier of the insurance carrier (NPI)

Service Line Paid Amount
(Loop: 2430, SVD02)

 

10
(numeric)

The total dollar amount paid for this service by the other payer

Adjudication Payment Date
(Loop: 2430, DTP03)

 

10
(numeric)

Date of payment or denial determination by Medicare payer for this service line

Claim Adjustment Group Code
(Loop: 2430, CAS01)

Refer to the MN–ITS screen for values available

 

HIPAA compliant adjustment group code listed on the insurance (other payer) EOB

Paid Unit Count
(Loop: 2430, SVD05)

 

1-15
(numeric)

The number of units identified as being paid from the other payer’s EOB

Adjustment Reason Code
(Loop: 2430, CAS02)

 

1-5
(alphanumeric)

Code identifying the reason the adjustment was made

Adjustment Amount
(Loop: 2430, CAS03)

 

10
(numeric)

The total dollar amount of the adjustment made to this service line

Adjustment Quantity
(Loop: 2430, CAS04)

 

1-15
(numeric)

The number of units being adjusted for this service line

Situational Services

Prior Authorization Number
(Loop: 2400, REF02)

 

11
(numeric)

Authorization number for the service when different than the authorization number reported at the claim level

Fixed Form Information
X12 Loop, 2400, K301)

 

1-80
(alphanumeric)

Field has no specific X12 use at this time

Tooth Code
(Loop: 2400, TOO02)

Refer to the MN–ITS screen for values available

 

Code identifying the tooth on which services were performed

Tooth Surface
(Loop: 2400 TOO03-1, TOO03-2, TOO03-3, TOO03-4, TOO03-5)

Refer to the MN–ITS screen for values available

 

Code identifying the area of the tooth that was treated

Oral Cavity Designation
(Loop 2400, SV304-1)

Refer to the MN–ITS screen for values available

 

Code identifying an oral cavity involved in the service

Prosthesis Code
(Loop: 2400, SV305)

Refer to the MN–ITS screen for values available

 

Code identifying if the placement status of the prosthesis

Prior Placement Date
(Loop: 2400, DTP03)

 

8
(numeric)

Date prior prosthetic was received

Orthodontic Banding Date
(Loop: 2400, DTP02)

 

8
(numeric)

Date initial banding was performed

Replacement Date
(Loop: 2400, DTP03)

 

8
(numeric)

Date orthodontic appliance was replaced

Other Providers (Line Level)

Rendering Provider – Provider Identifier NPI/UMPI
(Loop: 2420A, NM109)

 

10
(numeric)

NPI of the provider performing/rendering the service

Service Facility Location

Service Facility Location – Provider Identifier NPI/UMPI
(Loop2410C, NM109)

 

10
(numeric)

NPI identifying one of the following:

Where the service was actually provided

The recipient’s or provider’s home/clinic location when the location of health care service is different than the billing provider

Supervising Provider

Supervising Provider – Provider Identifier NPI/UMPI
(Loop: 2420C, NM109)

 

10
(numeric)

NPI of the provider supervising the service

Assistant Surgeon Provider

Assistant Surgeon Provider – Provider Identifier NPI/UMPI
(Loop: 2420B, NM109)

 

10
(numeric)

NPI of the assistant surgeon who performed the service