The segment map
Annotated example
A remittance for a Bluebird Dental claim containing a prophylaxis and a posterior composite:Reading it
BPR*I*210.38*C*ACH*CCP*... I = remittance information with payment. Total payment $210.38. C = credit. ACH with CCP = the ACH CCD+ format used for health care EFT. The remaining elements carry the originating and receiving bank routing and account numbers and the effective date 20260903.
TRN*1*DD20260901001*1234567890 The reassociation trace number DD20260901001. This value appears in the ACH addenda record of the corresponding EFT. This is how you match the deposit to this remittance.
CLP*PATACCT001*1*452.00*211.60*28.40*12*CLAIMCTRL9876*11
SVC*AD:D1110*142.00*98.00**1 Service line. AD qualifies a CDT code. This line reports D1110, adult prophylaxis, with 98.00 paid, and one unit.
CAS*CO*45*44.00 Adjustment: group code CO (contractual obligation), CARC 45 (charge exceeds fee arrangement), $44.00. If the adjustment is correct under the contract, post it as the PPO contractual write-off rather than billing the patient.
CAS*PR*2*28.40 Group code PR (patient responsibility), CARC 2 (coinsurance), $28.40; the patient’s 20% share of the composite’s allowed amount. After confirming the plan and prior payments, move the amount to the patient ledger.
PLB*1234567893*20261231*WO:CLAIMCTRL5432*1.22 Provider-level adjustment: WO = overpayment recovery, recouping $1.22 against prior claim CLAIMCTRL5432.
Tying the remittance to the deposit
The worked arithmetic:
The EFT for $210.38 will carry
DD20260901001 in its ACH addenda record.
Sum of claim payments ± PLB = BPR total = the deposit. Resolve any difference before posting. See Reconcile payments daily.
Downgrades and frequency limits in the 835
Downgrades and benefit limits do not have dedicated 835 segments. They arrive as ordinary adjustments, so posting logic needs to distinguish them from true denials. A downgraded line keeps the code you billed. When a plan applies an alternate-benefit clause, such as pricing a posterior composite at the amalgam allowable, theSVC still shows the submitted CDT code. The allowed amount reflects the less expensive alternative, and the difference appears in CAS with ordinary group and reason codes. Whether the patient owes any part of that difference depends on the plan and participation agreement, so use the actual group code rather than assuming. See Denials vs downgrades and Work your first downgrade.
Frequency limits and exhausted annual maximums can resemble denials. A third prophylaxis under a two-per-year plan, or a service after the annual maximum is exhausted, may return unpaid with a benefit-design adjustment. Confirm that the payer applied the plan correctly, then use the group code and contract terms to determine whether any amount moves to the patient.
Predeterminations arrive in the 835 too: claim status code 25 (see below) is a pricing-only response with no payment. Post it to the treatment plan, not the ledger.
Claim status codes (CLP02)
Route status
4 to the denial queue after ruling out a benefit-design adjustment. Status 22 unwinds a payment you already posted. Status 2 claims are a routine result of dental COB: a child covered under both parents’ plans generates a primary and a secondary remittance for the same visit.
PLB reason codes
Worked example: a refunded overpayment
A patient has dual coverage. Plan A is primary, Plan B is secondary.- Bluebird Dental seats a crown, D2740, and bills $1,200. Plan B is billed first and pays as though it were primary: $720.
- Plan A later pays its share for the same crown: $720. It arrives as a second remittance against a second claim. Total paid: $1,440 instead of $1,200.
- Plan B’s correct secondary liability was only $480. It has overpaid by $240 and requests it back.
- The practice writes Plan B a refund check for $240.
- Plan B’s next remittance acknowledges receipt, carrying two provider-level adjustments against the same claim:
WOfor $240 andB3for −$240.
WO records the $240 recovery, which on its own would reduce the deposit by that amount. The negative B3 increases the payment by the same amount, because the money arrived by check rather than by offset. The two net to zero and the deposit still equals the sum of claim payments on that remittance. Reason codes and sequencing differ between payers.
Why one 835 is not one deposit
Four independent reasons:- Aggregation, a payer may combine several remittances into one deposit
- Splitting, a large remittance may settle across multiple payments
- PLB, shifts the total away from the sum of claims
- Method, paper checks and virtual credit cards arrive on entirely different timelines than the 835, and dental payers still send plenty of both; see Paper checks and virtual credit cards
TRN reassociation trace number to match the 835 to the EFT. Dollar amounts alone are not a reliable key because unrelated payments can have the same amount.