837 Health Care Claim: Institutional - Louisiana Medicaid

06/30/2014 Health Care Claim: Institutional - 837NM1Receiver NamePos: 0200 Max: 1Heading - OptionalLoop: 1000B Elements: 5User Option (Usage): RequiredElement Summary:RefNM103Id1035Element NameName Last or Organization NameReqXTypeANMin/Max1/60LA Medicaid: Use the value LOUISIANA MEDICAIDMedicaid for this elementNM109 67 Identification Code X AN 2/80LA Medicaid: Use the value LA-DHH-MEDICAID for thiselementPRVUser Option (Usage): SituationalElement Summary:Billing Provider SpecialtyInformationPos: 0030 Max: 1Detail - OptionalLoop: 2000A Elements: 3RefPRV01Id1221Element NameProvider CodeReqMTypeIDMin/Max1/3LA Medicaid: Use the qualifier BI for this elementPRV02 128 Reference Identification Qualifier X ID 2/3LA Medicaid: Use the qualifier PXC for this element.Note: Qualifier changed from ZZ in 4010 transaction.PRV03 127 Reference Identification X AN 1/50LA Medicaid: Enter the Taxonomy Code associated with theNPI of the Billing Provider.This segment is required by Medicaid ONLY when Taxonomy isneeded for unique identification of the Medicaid Provider ID.In certain situations, a provider may have a single NPI that isassociated with multiple Louisiana Medicaid Provider numbers.To distinguish which Medicaid Provider number is beingreferenced, a “ Tie-Breaker” such as Taxonomy Code mustbesubmitted the same Taxonomy to assure the Code proper that cross was registered reference. for You themust Billing useProvider in the Louisiana Medicaid NPI Registration applicationfor the associated Medicaid Provider number.4