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

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Segment NameSegment IDLoop IDUsageSegment NotesIEAN/ARequiredInterchange Control TrailerElementIDUsage <strong>Guide</strong> Description/Valid Values CommentsIEA01 R Number of Included FunctionalGroupsUse the number of functional groupsincluded in this interchangeenvelope.IEA02 R Interchange Control Number Interchange control number IEA02in this trailer must be identical to thesame data element in theassociated interchange controlheader, ISA13, including paddedzeros.16
Outbound TransactionsSegmentNameSegment IDLoop IDUsageSegmentNotesISAN/ARequiredInterchange Control HeaderAll positions within each data element in the ISA segment must be filled.Delimiters are specified in the interchange header segment.The character immediately following the segment ID, ISA, defines the dataelements separator. The last character in the segment defines the componentelement separator, and the segment terminator is the byte that immediatelyfollows the component element separator. Examples of the separators are asfollows:Character Name Delimiter* Asterisk Data Element Separator: Colon Sub-element Separator~ Tilde Segment TerminatorWhile it is not required that submitters use these specific delimiters, they are the ones that thePEACH STATE HEALTH PLAN uses for all outbound transactions.Element Usage <strong>Guide</strong> Description/Valid Values CommentsIDISA01 R Authorization Information Qualifier00 – No AuthorizationInformation PresentISA02 R Authorization Information Always blank. Insert 10 blankspaces.ISA03 R Security Information Qualifier00 – No Security InformationPresentISA04 R Security Information Always blank. Insert 10 blankspaces.ISA05 R Interchange ID QualifierZZISA06 R Interchange Sender ID For batch transactions, this is thesender ID assigned by PEACH17
Page 1 and 2: 837P InboundCompanion GuideProfessi
Page 3 and 4: DocumentVersion NumberREVISION HIST
Page 5 and 6: (004010X096A1)Explanation ofASC X12
Page 7 and 8: InboundOutboundNCPDP (Provider)NCPD
Page 9 and 10: Provider Selection Criteria Informa
Page 11 and 12: • CoreFTP, CuteFtp, WSFTP ProIf y
Page 13 and 14: Element Usage Guide Description/Val
Page 15: ElementIDUsage Guide Description/Va
Page 19 and 20: ElementIDUsage Guide Description/Va
Page 21 and 22: SECTION 04: PROFESSIONAL CLAIM SUBM
Page 23 and 24: SegmentIDTable 3.1 - Segment Usage
Page 35 and 36: Segment and Data Element Descriptio
Page 37 and 38: IDDescription/ValidValuesREF01 R Re
Page 39 and 40: PER08 S CommunicationNumberPER09 N/
Page 41 and 42: PRV02 R ReferenceIdentification Qua
Page 43 and 44: U.S.N405 N/A Location Qualifier Not
Page 45 and 46: REF segment, in this loop.24: Emplo
Page 47 and 48: Segment NotesElement UsageIDGuideDe
Page 49 and 50: IDDescription/ValidValuesNM101 R En
Page 51 and 52: Segment NameSegment IDLoop IDUsageS
Page 53 and 54: 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 and 106:
B: Sample Audit ReportProcess Date
Page 107:
58 Invalid Mbr DOB; Invalid Prv; In
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837P Companion Guide - Peach State Health Plan Peach State ...

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