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

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Segment NameSegment IDLoop IDUsageSegment NotesElement UsageIDResponsibility Party City/State/Zip CodeN42010BCSituationalGuideDescription/ValidValuesN401 R Responsible PartyCity NameN402 R Responsible PartyState NameN403 R Responsible PartyPostal Zone or ZipCodeN404 S Responsible PartyCountry CodeN405 N/A Location Qualifier Not UsedN406 N/A Location Identifier Not UsedCommentsRequired if the address is out of theU.S.Segment Name Claim InformationSegment IDCLMLoop ID 2300UsageRequiredSegment NotesElementIDUsage GuideDescription/ValidValuesCLM01 R Patient AccountNumberCLM02 R Total Claim ChargeAmountCLM03 N/A Claim Filing IndicatorCodeCLM04 N/A Non- InstitutionalClaim type code54Not UsedNot UsedComments
CLM05 R Health Care ServiceLocation InformationCLM05- R Facility Type Code1CLM05- R Facility Code Qualifier02CLM05-03R Claim FrequencyCodeCLM06 R Provider or SupplierSignature IndicatorCLM07 S Medicare AssignmentCodeCLM08 R Benefits AssignmentCertification IndicatorCLM09 R Release of InformationCodeCLM10 S Patient SignatureSource CodeCLM11 S Related CausesInformationCLM11- R Related Causes Code1CLM11- S Related Causes Code2CLM11- S Related Causes Code3CLM11- S Auto Accident State or4CLM11-555N: NoY: YesN: NoY: YesNot UsedProvince CodeS Country Code Required if the automobile accidentoccurred out of the United States toidentify the country in which theaccident occurred.CLM12 S Special ProgramIndicatorCLM13 N/A Yes/No ConditionResponse CodeNot UsedCLM14 N/A Level of Service Code Not UsedCLM15 N/A Yes/No Condition Not UsedResponse CodeCLM16 S Participation
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 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: Segment IDLoop IDUsageSegment Notes
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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