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

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Segment NotesThis segment is used to respond to the functional groupinformation in the interchange envelope.Element IDAK101AK102UsageRRGuideDescription/ValidValuesFunctional IdentifierCodeTransaction SetControl NumberCommentsThe identifier code used for 997s generatedby PEACH STATE HEALTH PLANresponse to inbound 837 transactions.HC – Health Care Claim (837)This data element contains the value fromthe GS06 data element from the GSsegment of the original file beingacknowledged.Segment NameSegment IDLoopUsageSegment NotesTransaction Set Response HeaderAK2AK2SituationalThis segment is used to start the acknowledgment of atransaction set. If there are no errors at the transaction setlevel, this segment is not returned.ElementIDUsageGuideDescription/ValidValuesAK201 R Functional IdentifierCodeAK202 R Transaction SetControl NumberCommentsThe identifier code used for 997sgenerated by PEACH STATE HEALTHPLAN response to inbound 837transactions.HC – Health Care Claim (837)This data element contains the valuefrom the ST02 data element from the STsegment of the original file beingacknowledged.96
Segment NameSegment IDLoopUsageSegment NotesAK3AK2/AK3SituationalData Segment NoteThis segment is used to report segment/looping errors in thesubmitted transaction.Element Usage Guide Description/ValidCommentsIDValuesAK301 R Segment ID Code This data element lists the two or threebyte segment ID that contains theerror, such as ST, SBR.AK302 R Segment Position inTransaction SetThis data element contains thesequential position of the Segment IDidentified in AK301. This count beginswith 1 for the ST segment andincrements by 1 from that point.AK303 S Loop Identifier Code This data element identifies the loopAK304 S Segment Syntax ErrorCodewhere the erroneous segment resides.This data element describes the typeof error encountered.See code list in the IGSegment NameSegment IDLoopUsageSegment NotesData Segment NoteAK4AK2/AK3SituationalThis segment is used to report data element/composite errors inthe submitted transaction.ElementIDUsageGuideDescription/ValidValues97CommentsAK401 R Position in Segment This is a composite data element.
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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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Segment and Data Element Descriptio
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IDDescription/ValidValuesREF01 R Re
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PER08 S CommunicationNumberPER09 N/
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PRV02 R ReferenceIdentification Qua
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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 and 92: Identification QualifierREF02 R Sup
Page 93 and 94: N402 R Ordering ProviderState CodeN
Page 95: SECTION 05: ACKNOWLEDGEMENTS AND RE
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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