837P Companion Guide - Peach State Health Plan Peach State ...

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C: Audit Report Error Codes01 Invalid Mbr DOB02 Invalid Mbr06 Provider# or Medicaid TPI missing or does not match payer records / NPI07 Invalid Member DOB; Invalid Provider ID or TPI nbr08 Invalid Mbr & Prv09 Mbr not valid at DOS10 Invalid Mbr DOB; Mbr not valid at DOS12 Provider# inactive at DOS13 Invalid Mbr DOB; Prv not valid at DOS14 Invalid Mbr; Prv not valid at DOS15 Member inactive at DOS; Invalid Provider or TPI nbr16 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv17 Invalid Diag18 Invalid Mbr DOB; Invalid Diag19 Invalid Mbr; Invalid Diag21 Mbr not valid at DOS; Prv not valid at DOS22 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS23 Invalid Prv; Invalid Diag24 Invalid Mbr DOB; Invalid Prv; Invalid Diag25 Invalid Mbr; Invalid Prv; Invalid Diag26 Mbr not valid at DOS; Invalid Diag27 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag29 Prv not valid at DOS; Invalid Diag30 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag31 Invalid Mbr; Prv not valid at DOS; Invalid Diag32 Mbr not valid at DOS; Prv not valid; Invalid Diag33 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag34 Invalid Proc35 Invalid Mbr DOB; Invalid Proc36 Invalid Mbr; Invalid Proc38 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag39 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag40 Invalid Prv; Invalid Proc41 Invalid Mbr DOB, Invalid Prv; Invalid Proc42 Invalid Mbr; Invalid Prv; Invalid Proc43 Mbr not valid at DOS; Invalid Proc44 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Proc46 Prv not valid at DOS; Invalid Proc48 Invalid Mbr; Prv not valid at DOS; Invalid Proc49 Mbr not valid at DOS; Invalid Prv; Invalid Proc51 Invalid Diag; Invalid Proc52 Invalid Mbr DOB; Invalid Diag; Invalid Proc53 Invalid Mbr; Invalid Diag; Invalid Proc57 Invalid Prv; Invalid Diag; Invalid Proc
58 Invalid Mbr DOB; Invalid Prv; Invalid Diag; Invalid Proc59 Invalid Mbr; Invalid Prv; Invalid Diag; Invalid Proc60 Mbr not valid at DOS; Invalid Diag; Invalid Proc61 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag; Invalid Proc63 Prv not valid at DOS; Invalid Diag; Invalid Proc64 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag; Invalid Proc65 Invalid Mbr; Prv not valid at DOS; Invalid Diag; Invalid Proc66 Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc67 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc72 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc73 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc74 Rejected. Date of service prior to 6/1/2006.75 Invalid Units of service81 Invalid Units, Invalid Prv107
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837P InboundCompanion GuideProfessi
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DocumentVersion NumberREVISION HIST
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(004010X096A1)Explanation ofASC X12
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InboundOutboundNCPDP (Provider)NCPD
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Provider Selection Criteria Informa
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• CoreFTP, CuteFtp, WSFTP ProIf y
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Element Usage Guide Description/Val
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ElementIDUsage Guide Description/Va
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Outbound TransactionsSegmentNameSeg
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ElementIDUsage Guide Description/Va
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SECTION 04: PROFESSIONAL CLAIM SUBM
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SegmentIDTable 3.1 - Segment Usage
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Segment and Data Element Descriptio
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IDDescription/ValidValuesREF01 R Re
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PER08 S CommunicationNumberPER09 N/
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PRV02 R ReferenceIdentification Qua
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U.S.N405 N/A Location Qualifier Not
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REF segment, in this loop.24: Emplo
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Segment NotesElement UsageIDGuideDe
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IDDescription/ValidValuesNM101 R En
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Segment NameSegment IDLoop IDUsageS
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Segment IDLoop IDUsageSegment Notes
Page 55 and 56: CLM05 R Health Care ServiceLocation
Page 57 and 58: Segment Name Date - Onset of the cu
Page 59 and 60: DTP02 R Date Time PeriodFormat Qual
Page 61 and 62: Format QualifierDTP03 R RelatedHosp
Page 63 and 64: Loop ID 2300UsageSituationalSegment
Page 65 and 66: CR204 S Subluxation LevelCodeCR205
Page 67 and 68: Segment Name VisionSegment IDCRCLoo
Page 69 and 70: HI04-03 R Date Time PeriodFormat Qu
Page 71 and 72: First NameNM105 S Referring Provide
Page 73 and 74: last or OrganizationNameNM104 S Ren
Page 75 and 76: Segment NameSegment IDLoop IDUsageS
Page 77 and 78: SBR04 S Other Insured GroupNameSBR0
Page 79 and 80: NM103 R Other Insured LastNameNM104
Page 81 and 82: NM111 N/A Entity Identifier Code No
Page 83 and 84: SV118 N/A Postal Code Not UsedSV119
Page 85 and 86: CRC02 R Certification ConditionIndi
Page 87 and 88: ValuesREF01 R Reference6R: Provider
Page 89 and 90: PRV03 R ReferenceIdentificationProv
Page 91 and 92: Identification QualifierREF02 R Sup
Page 93 and 94: N402 R Ordering ProviderState CodeN
Page 95 and 96: SECTION 05: ACKNOWLEDGEMENTS AND RE
Page 97 and 98: Segment NameSegment IDLoopUsageSegm
Page 99 and 100: AK504 S Transaction Set SyntaxError
Page 101 and 102: Claim Audit ReportPEACH STATE HEALT
Page 103 and 104: SECTION 07: TESTINGSummaryThere are
Page 105: B: Sample Audit ReportProcess Date
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837P Companion Guide - Peach State Health Plan Peach State ...

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