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

Segment NotesElement UsageIDGuideDescription/ValidValuesHL01 R Hierarchical IDNumberHL02 R Hierarchical Parent IDNumberHL03 R Hierarchical LevelCodeHL04 R Hierarchical ChildCodeCommentsSegment NameSegment IDLoop IDUsageSegment NotesElement UsageIDSubscriber InformationSBR2000BRequiredGuideDescription/ValidValuesSBR01 R Payer ResponsibilitySequence NumberCode47CommentsCode:P: PrimaryS: SecondaryT: TertiaryUse to indicate ‘payor of last resort’18: SelfSBR02 S IndividualRelationship CodeSBR03 S Insured Group orPolicy NumberSBR04 S Insured Group Name Required if the subscriber’s payeridentification includes a Group or aPlan Name.SBR05 S Insurance TypeCodeSBR06 N/A Coordination ofBenefits CodeSBR07 N/A Yes/No Condition orResponse CodeNot UsedNot Used