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

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NM109 S Ordering ProviderIdentifierNM110 N/A Entity RelationshipCodeNM111 N/A Entity Identifier Code Not Used(NPI is required for typical providers.)If NM108 = 24, then give provider TIN, IRSnumber.If NM108 = 34, then give provider SSNIf NM108 = XX, then give provider NPINot UsedSegment NameSegment IDLoop IDUsageSegment NotesElement UsageIDOrdering Provider AddressN32420ESituationalGuideDescription/ValidValuesN301 R Ordering PhysicianAddress LineN302 S Ordering PhysicianAddress Line 2CommentsRequired if a second line exists.Segment NameSegment IDLoop IDUsageSegment NotesElement UsageIDOrdering Provider City/State/ZIP CodeN42420ESituationalGuideDescription/ValidValuesN401 R Ordering Provider CityName92Comments
N402 R Ordering ProviderState CodeN403 R Ordering ProviderPostal Zone or ZipCodeN404 S Ordering ProviderCountry CodeN405 N/A Location Qualifier Not UsedN406 N/A Location Identifier Not UsedRequired if the address is outsideof the U.S.Segment NameSegment IDLoop IDUsageSegment NotesElement UsageIDReferring Provider NameNM12420FSituationalGuideDescription/ValidValues93CommentsNM01 R Entity Identifier Code DN: Referring ProviderP3: Primary Care ProviderNM02 R Entity Type Qualifier 1: PersonNM03 R Referring ProviderLast NameNM04 R Referring ProviderFirst NameNM05 S Pr Referring ProviderMiddle NameNM06 N/A Name Prefix Not UsedNM07 S Referring ProviderName SuffixNM08 S Identification CodeQualifierIf “XX” is used, then either theEmployer’s Identification numberor the Social Security Number ofthe provider must be carried in theREF segment, in this loop.24: Employer IdentificationNumber34: Social Security number
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837P InboundCompanion GuideProfessi
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DocumentVersion NumberREVISION HIST
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(004010X096A1)Explanation ofASC X12
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InboundOutboundNCPDP (Provider)NCPD
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Provider Selection Criteria Informa
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• CoreFTP, CuteFtp, WSFTP ProIf y
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Element Usage Guide Description/Val
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ElementIDUsage Guide Description/Va
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Outbound TransactionsSegmentNameSeg
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ElementIDUsage Guide Description/Va
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SECTION 04: PROFESSIONAL CLAIM SUBM
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SegmentIDTable 3.1 - Segment Usage
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Page 33 and 34:
Page 35 and 36:
Segment and Data Element Descriptio
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IDDescription/ValidValuesREF01 R Re
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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 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: Identification QualifierREF02 R Sup
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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