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

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ElementIDUsage Guide Description/Valid Values CommentsFederal Tax NumberSTATE HEALTH PLAN This fieldhas a required length of 15 bytes;therefore, the field must be blankfilled to the right.ISA07 R Interchange ID QualifierZZ – Mutually DefinedISA08 R Interchange Receiver ID For batch transactions, this is thesender ID assigned by the TradingPartner. This field has a requiredlength of 15 bytes; therefore, thefield must be blank filled to the right.ISA09 R Interchange Date The date format is YYMMDD.ISA10 R Interchange Time The time format is HHMM.ISA11 R Interchange Control StandardsIdentifierU – U.S. EDI Community of ASCX12, TDCC, and UCSISA12 R Interchange Control VersionNumber00401 – Draft Standards forTrial Use Approved forPublication by ASC X12Procedures Review Boardthrough October 1997ISA13 R Interchange Control Number This number is unique andincrements by 1 with each ISAsegment. It also matches theinterchange control number of theIEA02 of the interchange controltrailer.ISA14 R Acknowledgment Requested1 – InterchangeAcknowledgment RequestedISA15 R Usage IndicatorP – Production DataT – Test Data18PEACH STATE HEALTH PLANalways requires an acknowledgmentfile for each file submitted to atrading partner.During testing the usage indicator isa T. After the trading partner hasapproved, the usage indicator willbe a P.
ElementIDUsage Guide Description/Valid Values CommentsISA16 R Component Element Separator The component element separatoris a delimiter and not a dataelement. This is always a colon ( :).Segment NameSegment IDLoop IDUsageSegment NotesGSN/ARequiredFunctional Group HeaderElementIDGS01 R Functional Identifier CodeHC – Health Care Claim (837)Usage Guide Description/Valid Values CommentsUse the appropriate identifier todesignate the type of transactiondata to follow the GS segment.GS02 R Application Sender’s Code Same as ISA06GS03 R Application Receiver’s Code Same as ISA08GS04 R Date The date format is CCYYMMDD.GS05 R Time The time format is HHMMSSGS06 R Group Control Number This data element contains auniquely assigned number andmatches the number in thecorresponding GS02 data elementon the GE group trailer segmentGS07 R Responsible Agency CodeX – Accredited StandardsCommittee X12GS08 R Version/Release/Industry IdentifierCode004010X098A1 – 837P004010X096A1 – 837 IThis data element contains theappropriate identifier to designatethe identifier code for the type oftransaction data to follow the GSsegment.19
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 and 16: ElementIDUsage Guide Description/Va
Page 17: Outbound TransactionsSegmentNameSeg
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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