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

SegmentIDTable 3.1 – Segment Usage – 837 ProfessionalLoop ID Segment Name IHCP UsageR – RequiredS – SituationalX – Not UsedNM1 2310E Supervising Provider Name SN2 2310E Additional Supervising ProviderName InformationREF 2310E Supervising Provider SecondaryInformationSBR 2320 Other Subscriber Information SCAS 2320 Claim Level Adjustment XAMT 2320 Coordination of Benefits (COB) XPayer Paid AmountAMT 2320 Coordination of Benefits (COB) XApproved AmountAMT 2320 Coordination of Benefits (COB) XAllowed AmountAMT 2320 Coordination of Benefits (COB) XPatient Responsibility AmountAMT 2320 Coordination of Benefits (COB) XCovered AmountAMT 2320 Coordination of Benefits (COB) XDiscount AmountAMT 2320 Coordination of Benefits (COB) Per XDay Limit AmountAMT 2320 Coordination of Benefits (COB) XPatient Paid AmountAMT 2320 Coordination of Benefits (COB) Tax XAmountAMT 2320 Coordination of Benefits (COB) XTotal Claim Before Taxes AmountDMG 2320 Subscriber DemographicInformationS28X – deleted peraddendaS