Dental

ApexEDI Dental Print Image Mapping 2006 Form (63 lines X 83 Columns)

Resources

Sample Print Image File

Print Image Mapping CSV

Field Name Line Column Length Value
Statement of Actual Services 4 3 1 X
Preauthorization 4 19 1 X
EPSDT 5 3 1 X
Preauthorization Number 6 20 21
Payer Name 9 3 30
Payer Address 1 10 3 30
Payer Address 2 11 3 30 American Fork, UT 84003-
Payer City, State Zip 12 3 30 0001
Other Coverage No 14 18 1 X
Other Coverage Yes 14 28 1 X
Other Subscriber Name 16 2 40 Last, First M
Other Subscriber DOB 18 2 10 10/30/2012
Other Subscriber Gender Male 18 17 1 X
Other Subscriber Gender Female 18 20 1 X
Other Subscriber ID 18 24 18
Other Subscriber Group Number 20 2 14
Other Subscriber Relationship Self 20 16 1 X
Other Subscriber Relationship Spouse 20 22 1 X
Other Subscriber Relationship Dependent 20 25 1 X
Other Subscriber Relationship Other 20 28 1 X
Other Payer Name 21 2 40
Other Payer Address 22 2 40 American Fork, UT 84003-
Other Payer City, State Zip 23 2 40 0001
Subscriber Name 8 43 38 Last, First M
Subscriber Address 9 43 38 American Fork, UT 84003-
Subscriber City, State Zip 10 43 38 0001
Subscriber DOB 12 43 12 10/30/2012
Subscriber Gender Male 12 58 1 X
Subscriber Gender Female 12 61 1 X
Subscriber ID 12 65 17
Subscriber Group Number 14 43 13
Subscriber Employer Name 14 57 25
Patient Relationship Self 17 44 1 X
Patient Relationship Spouse 17 49 1 X
Patient Relationship Child 17 55 1 X
Patient Relationship Other 17 64 1 X
Patient Student Status Full Time 17 72 1 X
Patient Student Status Part Time 17 77 1 X
Patient Name 19 43 38 Last, First M
Patient Address 20 43 38
Patient City, State Zip 21 43 38 American Fork, UT 84003-0001
Patient DOB 23 43 12 10/30/2012
Patient Gender Male 23 58 1 X
Patient Gender Female 23 61 1 X
Patient ID 23 64 17
Line Item Procedure Date 27-36 3 10 10/30/2012
Line Item Area of Oral Cavity 27-36 13 4
Line Item Tooth System 27-36 17 4
Line Item Tooth Numbers or Letters 27-36 21 10
Line Item Tooth Surface 27-36 32 5
Line Item Procedure Code 27-36 38 5
Line Item Description 27-36 44 31
Line Item Fee 27-36 76 6
Missing Teeth 1 37 18 1 X
Missing Teeth 2 37 20 1 X
Missing Teeth 3 37 22 1 X
Missing Teeth 4 37 24 1 X
Missing Teeth 5 37 26 1 X
Missing Teeth 6 37 28 1 X
Missing Teeth 7 37 30 1 X
Missing Teeth 8 37 32 1 X
Missing Teeth 9 37 34 1 X
Missing Teeth 10 37 36 1 X
Missing Teeth 11 37 38 1 X
Missing Teeth 12 37 40 1 X
Missing Teeth 13 37 42 1 X
Missing Teeth 14 37 44 1 X
Missing Teeth 15 37 46 1 X
Missing Teeth 16 37 48 1 X
Missing Teeth 17 38 48 1 X
Missing Teeth 18 38 46 1 X
Missing Teeth 19 38 44 1 X
Missing Teeth 20 38 42 1 X
Missing Teeth 21 38 40 1 X
Missing Teeth 22 38 38 1 X
Missing Teeth 23 38 36 1 X
Missing Teeth 24 38 34 1 X
Missing Teeth 25 38 32 1 X
Missing Teeth 26 38 30 1 X
Missing Teeth 27 38 28 1 X
Missing Teeth 28 38 26 1 X
Missing Teeth 29 38 24 1 X
Missing Teeth 30 38 22 1 X
Missing Teeth 31 38 20 1 X
Missing Teeth 32 38 18 1 X
Missing Teeth A 37 50 1 X
Missing Teeth B 37 52 1 X
Missing Teeth C 37 54 1 X
Missing Teeth D 37 56 1 X
Missing Teeth E 37 58 1 X
Missing Teeth F 37 60 1 X
Missing Teeth G 37 62 1 X
Missing Teeth H 37 64 1 X
Missing Teeth I 37 66 1 X
Missing Teeth J 37 68 1 X
Missing Teeth K 38 68 1 X
Missing Teeth L 38 66 1 X
Missing Teeth M 38 64 1 X
Missing Teeth N 38 62 1 X
Missing Teeth O 38 60 1 X
Missing Teeth P 38 58 1 X
Missing Teeth Q 38 56 1 X
Missing Teeth R 38 54 1 X
Missing Teeth S 38 52 1 X
Missing Teeth T 38 50 1 X
Total Fee 38 74 8
Remarks 1 39 7 75
Remarks 2 40 2 80
Patient Signature 45 3 26 SIGNATURE ON FILE
Patient Signature Date 45 30 10 10/30/2012
Subscriber Signature 49 3 26 SIGNATURE ON FILE
Subscriber Signature Date 49 30 10 10/30/2012
Place of Treatment Office 43 44 1 X
Place of Treatment Hospital 43 52 1 X
Place of Treatment ECF 43 57 1 X
Place of Treatment Other 43 61 1 X
Number of Enclosures Radiograph 43 69 2 01
Number of Enclosures Oral Images 43 74 2 00
Number of Enclosures Models 43 79 2 00
Is Treatment for Orthodontics No 45 44 1 X
Is Treatment for Orthodontics Yes 45 53 1 X
Date Appliance Placed 45 66 10 10/30/2012
Months of Remaining Treatment 47 44 5
Replacement of Prosthesis No 47 53 1 X
Replacement of Prosthesis Yes 47 56 1 X
Date Prior Placement 47 66 10 10/30/2012
Treatment Resulting From Occupational 49 44 1 X
Treatment Resulting From Auto Accident 49 59 1 X
Treatment Resulting From Other Accident 49 69 1 X
Date of Accident 50 57 10 10/30/2012
Auto Accident State 50 80 2
Billing Provider Name 53 2 40
Billing Provider Address 1 54 2 40
Billing Provider Address 2 55 2 40
Billing Provider City, State Zip 56 2 40 American Fork, UT 84003-0001
Billing Provider NPI 58 2 13
Billing Provider License Number 58 15 13
Billing Provider SSN-TIN 58 28 13
Billing Provider Phone 59 8 14 801 642 0300
Treating Provider Signature 53 44 26 SIGNATURE ON FILE
Treating Provider Signature Date 53 71 10
Treating Provider NPI 55 48 13
Treating Provider License Number 55 69 13
Treating Provider Address 57 43 39
Treating Provider City, State Zip 58 43 39 American Fork, UT 84003-0001
Treating Provider Specialty Code 56 69 12
Treating Provider Phone 59 48 14 801 642 0300