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

Segment NameSegment IDLoop IDUsageSegment NotesElement UsageIDPayer City/State/Zip CodeN42010BBRequiredGuideDescription/ValidValuesN401 R Payer City NameCommentsN402 R Payer State CodeN403 R Payer Postal Zone orPost CodeN404 S Payer Country Code This data element is required if theaddress is outside of the U.S.N405 N/A Location Qualifier Not UsedN406 N/A Location Identifier Not UsedSegment NameSegment IDLoop IDUsageSegment NotesElement UsageIDPayer Secondary IdentificationREF2010BBRequiredGuideDescription/ValidValuesREF01 R ReferenceIdentification QualifierREF02 R Payer AdditionalIdentifierREF03 N/A Description Not UsedREF04 N/A Reference Identifier Not UsedComments2U: Payer Identification NumberFY: Claim Office NumberNF: National Association ofInsurance Commissioners CodeTJ: Federal Taxpayer’sIdentification NumberSegment NameResponsible Party Name52