Medicare Advantage Dental Validation Report Layout Clean 2-28-2024

Medicare Advantage Dental Validation Report Layout

The Medicare Advantage (MA) Dental Validation Report generates once an MA Dental file is accepted at the interchange and functional group levels and is returned to the submitter of the data. The source data within this report is extracted from the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3; Health Care Claim: Dental (837), Acknowledgement (277), and the Customer Service Front End System (CSFES). The Errored Segment and Error Code fields will only appear in this report when an error has occurred. An ICN will not be returned when the encounter is rejected.

The following layout provides the MA Dental Validation Report field name, the source location, and the field name within the source location. The Comments column provides additional information when the data presented within the report is generated by the CSFES.

Field Name	Source X12 Transaction	Source Field Name	Comments
File ID	Dental 837	ISA13
Submitter ID	Dental 837	ISA06
Submitter Name	Dental 837	1000A-NM103
Transaction ID	Dental 837	ST02
Errored Segment	Dental 837		The segment preceding the STC segment
Error Code	Acknowledgement (277)	2200B-STC01, STC10, STC11	The error code(s) generated will display in this field. This error applies to the whole ST/SE Loop
Billing Provider ID	Dental 837	2010AA-NM109
Billing Provider Name	Dental 837	2010AA-NM103
Errored Segment	Dental 837		The segment preceding the error segment
Error Code	Acknowledgement (277)	2200C-STC01, STC10, STC11	The error code(s) generated will display in this field. This error applies to all encounters associated with this Billing Provider
Subscriber Name	Dental 837	2010BA-NM103 - 07
HICN	Dental 837	2010BA-NM109
Patient Control Number	Dental 837	2300-CLM01
Trace Number	Dental 837	2300-REF-D9
ICN	CSFES	2300-REF-ICN	The CSFES assigned ICN number will display in this
Encounter Status	Dental 837	2200D-STC03	This field will reflect the status of the encounter (Accepted or Rejected)
Errored Segment	Dental 837		The segment preceding the STC segment

Error Code	Acknowledgement (277)	2200D-STC01, STC10, STC11	The error code(s) generated will display in this field. This error applies to the Claim Level of this specific encounter
Line REF	Dental 837	2400-LX01
Errored Segment	Dental 837		The segment preceding the STC segment
Error Code	Acknowledgement (277)	2220D-STC01, STC10, STC11	The error code(s) generated will display in this field. This error applies to a Service Line in this specific encounter
Overall Totals	CSFES		File level totals