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

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AK401-1 RSegment Position inTransaction SetAK401-2 S Component DataElement Position inCompositeAK403 S Data Element ReferenceNumberAK404 R Data Element SyntaxError CodeAK405 S Copy of Bad DataElementThis data element contains thesequential position of the simple dataelement or composite data structure.This count begins with 1 for the initialelement and increments by 1 from thatpoint.This data element identifies within thecomposite structure where the erroroccurs.This is the Data Element Dictionaryreference number associated with theerroneous data element/composite.This data element describes the type oferror encountered.See code list in IGSegment NameSegment IDLoopUsageSegment NotesTransaction Set Response TrailerAK5AK2/AK3RequiredThis segment is used to acknowledge the acceptance or rejectionof a transaction and any report errors.ElementIDUsage<strong>Guide</strong>Description/ValidValuesAK501 R Transaction SetAcknowledgment CodeAK502 S Transaction Set SyntaxError CodeAK503 S Transaction Set SyntaxError CodeCommentsA: AcceptedR: RejectedThis data element describes the type oferror encountered.See code list in IGThis data element describes the type oferror encountered.98
AK504 S Transaction Set SyntaxError CodeAK505 S Transaction Set SyntaxError CodeAK506 S Transaction Set SyntaxError CodeSee code list in IGThis data element describes the type oferror encountered.See code list in IGThis data element describes the type oferror encountered.See code list in IGThis data element describes the type oferror encountered.See code list in IGSegment NameSegment IDLoopUsageSegment NotesFunctional Group Response TrailerAK9N/ARequiredThis segment is used to acknowledge the acceptance or rejectionof a functional group and report the number of transaction setsoriginally included, received, and accepted.ElementIDUsage<strong>Guide</strong>Description/ValidValuesAK901 R Functional GroupAcknowledgment CodeAK902 S Number of TransactionSets IncludedAK903 S Number of ReceivedTransaction SetsAK904 S Number of AcceptedTransaction SetsAK905 S Functional Group SyntaxError Code99CommentsA: AcceptedR: RejectedP: Partial (Rejected)This data element contains thevalue from the GE01 data elementfrom the GE segment of theoriginal file being acknowledged.This data element describes thetype of error encountered.
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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
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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 and 96: SECTION 05: ACKNOWLEDGEMENTS AND RE
Page 97: Segment NameSegment IDLoopUsageSegm
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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