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

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SegmentIDTable 3.1 – Segment Usage – 837 ProfessionalLoop ID Segment Name IHCP UsageR – RequiredS – SituationalX – Not UsedREF 2300 Mammography Certification Number XREF 2300 Prior Authorization or ReferralNumberREF 2300 Original Reference Number(ICN/DCN)REF 2300 Clinical Laboratory ImprovementAmendment (CLIA)REF 2300 Repriced Claim Number XREF 2300 Adjusted Repriced Claim Number XREF 2300 Investigational Device ExemptionNumberREF 2300 Claim Identification Number for SClearinghouses and OtherTransmission IntermediariesREF 2300 Ambulatory Patient Group (APG) XREF 2300 Medical Record Number XREF 2300 Demonstration Project Identifier XK3 2300 File Information XNTE 2300 Claim Note XCR1 2300 Ambulance Transport Information SCR2 2300 Spine Manipulation ServiceSInformationCRC 2300 Ambulance Certification SCRC 2300 Patient Condition Information: Vision SCRC 2300 Homebound Indicator XCRC 2300 EPSDT Referral SHI 2300 Health Care Diagnosis Code R26SXXX
SegmentIDTable 3.1 – Segment Usage – 837 ProfessionalLoop ID Segment Name IHCP UsageR – RequiredS – SituationalX – Not UsedHCP 2300 Claim Pricing/Repricing Information XCR7 2305 Home Health Care Plan Delivery XHSD 2305 Health Care Services Delivery XNM1 2310A Referring Provider Name SPRV 2310A Referring Provider SpecialtyInformationN2 2310A Additional Referring Provider NameInformationREF 2310A Referring Provider SecondaryInformationNM1 2310B Rendering Provider Name SPRV 2310B Rendering Provider Specialty SInformationN2 2310B Additional Rendering Provider NameInformationREF 2310B Rendering Provider SecondaryInformationNM1 2310C Purchased Service Provider Name XREF 2310C Purchased Service Provider XSecondary InformationNM1 2310D Service Facility Location XN2 2310D Additional Service Facility LocationName InformationN3 2310D Service Facility Location Address XN4 2310D Service Facility LocationXCity/State/ZIP CodeREF 2310D Service Facility Location SecondaryInformationX27SX – deleted peraddendaSX – deleted peraddendaSX – deleted peraddenda
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 and 18: Outbound TransactionsSegmentNameSeg
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 25: 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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