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

ElementIDUsageGuideDescription/ValidValuesN401 R Pay to Provider CityNameN402 R Pay to Provider StateCodeN403 R Pay to Provider ZipCodeN404 S Pay to ProviderCountry CodeN405 N/A Location Qualifier Not UsedN406 N/A Location Identifier Not UsedCommentsRequired if the address is outsideof the U.S.Segment NameSegment IDLoop IDUsageSegment NotesElement UsageIDREF01 R ReferenceIdentification QualifierREF02 R Pay to ProviderIdentifierPay –to Provider Secondary InformationREF2010ABSituationalRequired if Pay-to provider information suppliedGuideCommentsDescription/ValidValuesREF03 N/A Description Not UsedREF04 N/A Reference Identifier Not Used1D = Provider Medicaid NumberG2 = Provider Commercial NumberEI = Employer Identification numberMedicaid numbers can be a minimumof 9 positions up to 11 positions inlengthSegment NameSegment IDLoop IDUsageSubscriber Hierarchical LevelHL2000BRequired46