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

NM103 R Other Insured LastNameNM104 S Other Insured FirstNameNM105 S Other Insured MiddleNameNM106 N/A Name PrefixNM107 S Other Insured NameSuffixNM108 R Identification CodeQualifierNM109 R Supervising ProviderPrimary IdentifierNM110 N/A Entity RelationshipCodeNM111 N/A Entity Identifier CodeMI: Member Identification NumberZZ: Mutually DefinedSegment NameSegment IDLoop IDUsageSegment NotesElement UsageIDOther Subscriber AddressN32330ASituationalGuideDescription/ValidValuesN301 R Other Insured AddressLineN302 S Other Insured AddressLine 2CommentsRequired if a second address lineexists.Segment NameSegment IDLoop IDUsageSegment NotesOther Subscriber City/State/ZIP CodeN42330ASituational79