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

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SV101- S Procedure Modifier06SV101- N/A Description Not Used07SV102 R Line Item ChargeAmountSV103 R Unit or Basis forMeasurement CodeSV104 R Service Unit CountSV105 S Place of Service CodeSV106 N/A Service Type Code Not UsedSV107 R Composite DiagnosisCode PointerSV107-01R Diagnosis CodePointerSV107-02S Diagnosis CodePointerSV107-03S Diagnosis CodePointerSV107-04S Diagnosis CodePointerSV108 N/A Monetary Amount Not UsedSV109 R Emergency IndicatorSV110 N/A Multiple Procedure Not UsedCodeSV111 S EPSDT Indicator Y: YesSV112 S Family Planner Y: YesIndicatorSV113 N/A Review Code Not UsedSV114 N/A National or Local Not UsedAssigned ReviewValueSV115 S Co-Pay Status Code 0: Copay ExemptSV116 N/A Health CareNot UsedProfessional ShortageAreaSV117 N/A ReferenceIdentificationNot Used82
SV118 N/A Postal Code Not UsedSV119 N/A Monetary Amount Not UsedSV120 N/A Level of Care Code Not UsedSV121 N/A Provider AgreementCodeNot UsedSegment Name Ambulance Transport InformationSegment IDCR1Loop ID 2400UsageSituationalSegment NotesElement Usage GuideCommentsIDDescription/ValidValuesCR101 S Unit or Basis for LB: PoundMeasurement CodeCR102 S Patient WeightCR103 R Ambulance TransportCodeCR104 R Ambulance TransportReason CodeCR105 R Unit or Basis for DH: MilesMeasurement CodeCR106 R Transport DistanceCR107 N/A Address Information Not UsedCR108 N/A Address Information Not UsedCR109 S Round Trip PurposeDescriptionCR110 S Stretcher PurposeDescriptionRequired if needed to justify theusage of a stretcher.Segment Name Spinal Manipulation Service InformationSegment IDCR2Loop ID 2400UsageSituational83
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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 25 and 26:
Page 27 and 28:
Page 29 and 30:
Page 31 and 32: SegmentIDTable 3.1 - Segment Usage
Page 33 and 34: 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 and 54: Segment IDLoop IDUsageSegment Notes
Page 55 and 56: CLM05 R Health Care ServiceLocation
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: NM111 N/A Entity Identifier Code No
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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