Pennsylvania
PROMISe™
Companion Guide
837 Dental
Version 5010
September 2010, Version 1
Pennsylvania PROMISe™ – 837 Dental Companion Guide
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September 2010
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Table
of
Contents
Overview ...................................................................................................................................................... 1
Companion Guide Instructions.................................................................................................................. 2
Revisions to the Companion Guide ........................................................................................................... 3
Pennsylvania General HIPAA Data Elements ......................................................................................... 4
Pennsylvania Specific HIPAA Data Elements.......................................................................................... 7
Appendix A – Insurance Carriers ........................................................................................................... 51
September 2010
Pennsylvania PROMISe™ – 837 Dental Companion Guide
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September 2010
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Overview
The Pennsylvania Department of Public Welfare's HIPAA-compliant Provider Reimbursement
and Operations Management Information System (PROMISe™) has adopted the new version
5010 X12 standards. These standards are in compliance with the CMS mandate
effective January 1, 2012.
This Companion Guide contains detailed instructions for preparing 837 Dental transaction
records for all of the different types of services that can be submitted to PROMISe™ in the 837
Dental format. Please disregard any instructions that do not pertain to the services for
which you are submitting.
Submitters (individual providers, billing services, software vendors, and managed care
organizations) must complete a certification process in order to submit transactions to
PROMISe™ for production processing. The certification process consists of the submission of
test claims to verify that all transactions are HIPAA compliant and conform to PROMISe™. To
initiate the certification process, see the certification registration process on the DPW web site
at http://www.dpw.state.pa.us/PartnersProviders/PROMISe/ or contact the HP Enterprise
Services Provider Assistance Center at 800-248-2152.
September 2010
Page 1
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Companion
Guide
Instructions
One of the new terms born out of HIPAA is payer variability. As each payer works to make its
system HIPAA-compliant, there is a realization and an allowance that payers require information
and values/formats specific to their systems. As such, each payer requires that transactions be
completed with specific data. This Companion Guide was developed to communicate the
Pennsylvania Medical Assistance-specific information required to successfully submit the 837
Dental transaction.
This Companion Guide is to be used in conjunction with the CMS HIPAA Implementation Guide
found at http://www.wpc-edi.com. The CMS HIPAA Implementation Guide is the main source of
information about the transaction sets. The Companion Guide contains:
•
DPW interpretation/application of the data elements that support Medical Assistance
transaction submissions,
•
The methods utilized to convey data that are not included in the CMS HIPAA
Implementation Guide, but are required for processing Pennsylvania Department of Public
Welfare transactions; and
•
Clarification for certain, less obvious, but still standard, uses of the transaction.
September 2010
Page 2
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Revisions to the
Companion Guide
To aid the provider community in organizing these Companion Guides and the revisions that
may occur, this document will have a revision schedule and notification process.
The initial release of this Companion Guide is September 2010. The first release reflects all the
known information as of this date. However, as the implementation phases of PROMISe™
progress, updates and releases of new information may be forthcoming.
Revision Process:
For each new release of this Companion Guide, the information that has been changed since
the previous version will be located in this section of the guide. If a revision is made to a data
element, it will be detailed in the Revision(s) Description section in the table containing the
element. DPW will clearly define the change that was made so it can be integrated into your
process.
Updated releases of the Transaction Guide will be posted on the DPW website. You are
encouraged to check this site regularly.
Revision(s)
Description
September 2010
9/1/2010 – Original 5010 Version
Page 3
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Pennsylvania
General HIPAA
Data Elements
Managed Care
Encounter Data
The managed care organization (MCO) will be treated as a previous
payer and as the submitter.
•
•
•
•
•
The MCO identifies the transaction as an encounter by
reporting ‘RP’ (Reporting) in BHT06 (Transaction Type
Code).
The MCO identifies themselves as the submitter by putting
their PROMISe™ MPI Number and Service Location Code
into Loop 1000A, Data Element NM109 (Submitter Primary
Identifier).
The MCO identifies themselves as a previous payer by putting
their payer information in Loops 2320 and 2330B.
The MCO identifies their adjudication information by using
Loops 2320 and 2430. Pennsylvania PROMISe™ is
expecting the value ‘HM’ in Loop 2320, Data Element SBR09
(Claim Filing Indicator) when the payer is an MCO.
The MCO must send their MCO-specific internal control
number in Loop 2330B, Segment REF (Other Payer Claim
Control Number), using REF01=’F8’ as the qualifier.
Loop 2300, Segment CLM, Data Element CLM01 must also contain
the MCO’s internal control number (ICN). The number that the MCO
transmits in this position is echoed back in the 277 Claim Status
Response, Detail Level; Loop 2200D (Claim Submitter’s Trace
Number). TRN02 will be set to the Patient Account Number
submitted on the original claim in Loop 2300, Segment CLM, and
Data Element CLM01.
September 2010
•
The MCO reports sub-capitation arrangements by using the
Contract Information segment (CN1) in Loop 2300.
•
The MCO must report a claim adjudication date in the 2330B
Loop, DTP segment, even when service line adjudication
dates are reported in Loop 2430 at the service line level. If
there are multiple adjudication dates at the service line level
the most recent adjudication date at the service line level
should be reported in Loop 2330B.
Page 4
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Claims With Prior
Authorization
Claims With
Attachments
EPSDT Claims
When required, the submitter must submit the prior authorization
number in Loop 2300, Segment REF (Prior Authorization) and follow
the CMS HIPAA Implementation Guide rules for submitting prior
authorization numbers.
•
When required, the submitter must obtain an attachment
™
control number (ACN) from the PA PROMISe Web site at
http://promise.dpw.state.pa.us/ and submit it in Loop 2300,
Segment PWK (Claim Supplemental Information), following
the CMS HIPAA Implementation Guide rules for submitting
attachments.
•
The Batch Cover form with the ACN must be present on all
paper attachments. The ACN on the paper attachments must
match the ACN entered on the related claim. The Batch
Cover form and paper attachments are submitted to DPW and
must be received within 14 days of the claim submission date,
otherwise the claim will reject.
•
The submitter must supply the appropriate EPSDT codes in
Loop 2300 Segment NTE (Claim Note).
Co-Payment
Information
The 837 Implementation Guide was not designed to show exceptions
to co-payment. Pennsylvania PROMISe™ will use Loop 2300
segment NTE (Claim Note) as the place to submit the co-payment
exemptions or failure of the recipient to pay the co-pay.
General Provider
Information
All provider entities who participated in the claim should be reported
in accordance with the implementation guide rules.
PROMISe™ uses taxonomy codes and zip code + four to resolve a
single NPI to one of the many PROMISe™ service location codes
that the provider uses. Therefore, it is essential that providers who
are sending National Provider IDs (NPI) also provide the taxonomy
code and zip code + four that matches their enrollment for the
specific service location code that is intended where those codes are
available.
September 2010
Page 5
Pennsylvania PROMISe™ – 837 Dental Companion Guide
General Claim
September 2010
Pennsylvania PROMISe™ will capture any of the Loops and
Segments that are included in the CMS HIPAA Implementation
Guide and are sent in the transaction. Where not specifically
mentioned in this Companion Guide, the Loops, Segments, and Data
Elements must be used in accordance with the Implementation Guide.
The claim must pass CMS HIPAA Compliance edits before it can be
processed in PROMISe™.
Page 6
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Pennsylvania
Specific HIPAA
Data Elements
Page
#
B.3
Field Name
5010 New values, Functions
Description of 5010
Change
ISA01:
Authorization
Information
Qualifier
PROMISe™ Specific
Instructions
Use "00"
ISA02:
Authorization
Information
Use 10 spaces
ISA03: Security
Information
Qualifier
Use "00"
ISA04: Security
Information
Use 10 spaces
ISA05:
Interchange ID
Qualifier
Use "ZZ"
ISA06:
Interchange
Sender ID
Use your assigned BBS
ID
ISA07:
Interchange ID
Qualifier
Use "ZZ"
ISA08:
Interchange
Receiver ID
Production - 345529167
Testing - 445314156
ISA09:
Interchange Date
ISA10:
Interchange Time
ISA11:
Interchange
Control Standards
Identifier
September 2010
Change to replace the
constant U with a
character that
represents a repeating
data separator
Recommend using "^"
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
ISA12:
Interchange
Control Version
Number
5010 New values, Functions
"00501"
Description of 5010
Change
Changes the value to
show that the
transaction is a 5010
version
PROMISe™ Specific
Instructions
ISA13:
Interchange
Control Number
ISA14:
Acknowledgemen
t Requested
ISA15: Usage
Indicator
ISA16:
Component
Element Separator
B.8
GS01: Functional
Identifier Code
"HC"
GS02: Application
Sender's Code
GS03: Application
Receiver's Code
Production - use
"345529167"
Testing - use
"445314156"
GS04: Date
GS05: Time
HHMMSSDD
Adds seconds and
tenths of seconds
GS08: Version,
Release, Industry
Identifier Code
"005010X224A2"
Changes the value of
to show that the
transaction is a 5010
837 Dental
ST01: Transaction
Set Identifier
Code
837
GS06: Group
Control Number
GS07:
Responsible
Agency Code
65
ST02: Transaction
Set Control
Number
September 2010
HHMM recommend
format
Pennsylvania PROMISe™ – 837 Dental Companion
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Page
#
Field Name
ST03:
Implementation
Convention
Reference
66
5010 New values, Functions
"005010X224A2"
Description of 5010
Change
Changes the value to
show that the
transaction is a 5010
837 Dental
PROMISe™ Specific
Instructions
BHT01:
Hierarchical
Structure Code
BHT02:
Transaction Set
Purpose Code
BHT03:
Originator
Application
Transaction
Identification
BHT04:
Transaction Set
Creation Date
BHT05:
Transaction Set
Creation Time
BHT06: Claim or
Encounter
Indicator
"CH", "RP", "31"
LOOP 1000A:
SUBMITTER
NAME
69
NM101: Entity
Identifier Code
"41"
NM102: Entity
Type Qualifier
"1", "2"
NM103:
Submitter Last or
Organizational
Name
NM104:
Submitter First
Name
NM105:
Submitter Middle
Name
September 2010
Use only "CH" for
Claims or "RP" for
Encounters
Pennsylvania PROMISe™ – 837 Dental Companion
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Page
#
Field Name
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
NM108:
Identification
Code Qualifier
NM109:
Submitter
Identifier
71
PER Submitter
Contact EDI
Contact
Information
PROMISe™ does not
use contact (PER)
segments
LOOP 1000B:
RECEIVER
NAME
74
NM101: Entity
Identifier Code
"40"
NM102: Entity
Type Qualifier
"2"
NM103: Receiver
Name
Use "Department of
Public Welfare"
NM108:
Identification
Code Qualifier
NM109: Receiver
Primary Identifier
Use "236003113"
LOOP 2000A:
BILLING
PROVIDER
HIERARCHICAL
LEVEL
76
HL01:
Hierarchical ID
Number
HL03:
Hierarchical Level
Code
HL04:
Hierarchical Child
Code
78
PRV01: Provider
Code
September 2010
"BI"
Pennsylvania PROMISe™ – 837 Dental Companion
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Page
#
Field Name
PRV02: Reference
Identification
Qualifier
5010 New values, Functions
"PXC"
Description of 5010
Change
Changed qualifier for
Taxonomy Codes
PROMISe™ Specific
Instructions
PROMISe™ needs the
Taxonomy Code for all
provider entities who
have a Taxonomy
Segment
PRV03: Provider
Taxonomy Code
79
CUR Currency
Code
PROMISe™ does not
use the Currency
Segment
LOOP 2010AA:
BILLING
PROVIDER
NAME
82
NM101: Entity
Identifier Code
"85"
NM102: Entity
Type Qualifier
"1", "2"
NM103: Billing
Provider Last or
Organizational
Name
NM104: Billing
Provider First
Name
NM105: Billing
Provider Middle
Name
NM107: Billing
Provider Name
Suffix
NM108:
Identification
Code Qualifier
NM109: Billing
Provider Identifier
September 2010
"XX"
Changed from required
to situational. Can
only be sent if the
Billing Provider
primary ID is an NPI
Changed from required
to situational. Can
only be sent if the BP
primary ID is an NPI
(qualifier = XX)
Pennsylvania PROMISe™ – 837 Dental Companion
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#
86
Field Name
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
N301: Billing
Provider Address
Line
N302: Billing
Provider Address
Line
87
N401: Billing
Provider City
Name
N402: Billing
Provider State or
Province Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
N403: Billing
Provider Postal
Zone or ZIP Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
PROMISe™ needs the
zip code and extension
for all provider entities
who have an address
segment.
EI, SY
New
This segment is required
for all Billing Providers.
"0B","IG"
Shortened list of
allowed secondary
Identifier qualifiers
N404: Billing
Provider Country
Code
89
REF01: Reference
Identification
Qualifier
REF02: Billing
Provider Tax
Identification
Number
91
REF01: Reference
Identification
Qualifier
REF02: Billing
Provider License
and/or UPIN
Information
93
PER
PROMISe™ does not
use contact (PER)
segments
LOOP 2010AB:
PAY-TO
ADDRESS
NAME
PROMISe™ will not
use the Pay-To Address
Loop
September 2010
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
Description of 5010
Change
LOOP 2010AC:
PAY-TO PLAN
NAME
PROMISe™ Specific
Instructions
PROMISe™ will not
use the Pay-To Plan
Loop
LOOP 2000B:
SUBSCRIBER
HIERARCHICAL
LEVEL
109
HL01:
Hierarchical ID
Number
HL02:
Hierarchical
Parent ID Number
HL03:
Hierarchical Level
Code
HL04:
Hierarchical Child
Code
111
SBR01: Payer
Responsibility
Sequence Number
Code
SBR02: Individual
Relationship Code
New Listing of Payer
Ordering up to 11
distinct payers
"18"
SBR03:
Subscriber Group
or Policy Number
None
SBR04:
Subscriber Group
Name
None
SBR05: Insurance
Type Code
Usage changed from
not used to situational
SBR09: Claim
Filing Indicator
Code
September 2010
"MC", "TV", "OF"
"“WM” for women’s
medical services and
non-invasive
contraceptive supplies
“BC” for breast cancer
screenings
“FP” for all other Title
XX services"
"PROMISe™ values are
"MC" for Medicaid
"TV" for Title V
"OF" for Title XX
Pennsylvania PROMISe™ – 837 Dental Companion
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#
Field Name
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
LOOP 2010BA:
SUBSCRIBER
NAME
114
NM101: Entity
Identifier Code
"IL"
NM102: Entity
Type Qualifier
"1", "2"
NM103:
Subscriber Last
Name
NM104:
Subscriber First
Name
NM105:
Subscriber Middle
Name
NM107:
Subscriber Name
Suffix
NM108:
Identification
Code Qualifier
NM109:
Subscriber
Primary Identifier
117
"MI" = Member
Identification
Usage changed from
situational to required
Usage changed from
situational to required
N301: Subscriber
Address Line
N302: Subscriber
Address Line
118
N401: Subscriber
City Name
N402: Subscriber
State or Province
Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
N403 : Subscriber
Postal Zone or
ZIP Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
September 2010
This is the PROMISe™
recipient ID
Pennsylvania PROMISe™ – 837 Dental Companion
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#
Field Name
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
N404: Subscriber
Country Code
120
122
DMG01: Date
Time Period
Format Qualifier
"D8"
DMG02:
Subscriber Birth
Date
CCYYMMDD
DMG03:
Subscriber Gender
Code
"F", "M", "U"
REF01:
Referenced
Identification
Qualifier
"SY"
REF02:
Subscriber
Supplemental
Identifier
123
REF01: Reference
Identification
Qualifier
REF02: Property
Casualty Claim
Number
LOOP 2010BB:
PAYER NAME
124
NM101: Entity
Identifier Code
NM102: Entity
Type Qualifier
NM103: Payer
Name
Use "Department of
Public Welfare"
NM108:
Identification
Code Qualifier
NM109: Payer
Identifier
126
N301: Payer
Address Line
September 2010
Use "236003113"
Pennsylvania PROMISe™ – 837 Dental Companion
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#
Field Name
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
N302: Payer
Address Line
127
N401: Payer City
Name
Use "Harrisburg"
N402: Payer State
Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
Use "PA"
N403: Payer
Postal Zone or
ZIP Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
Use "171069022"
New Segment for
Billing Provider's
Secondary IDs
Use "G2" for Atypical
Providers' Legacy
(MAID)
N404: Payer
Country Code
129
REF01:
Referenced
Identification
Qualifier
REF02: Payer
Secondary
Identifier
131
REF01:
Referenced
Identification
Qualifier
REF02: Billing
Provider
Secondary
Identification
LOOP 2000C:
PATIENT
HIERARCHICAL
LEVEL
133
HL01:
Hierarchical ID
Number
HL02:
Hierarchical
Parent ID Number
September 2010
"G2", "LU"
Atypical Billing
Providers will send their
Legacy (MAID) here
Pennsylvania PROMISe™ – 837 Dental Companion
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#
Field Name
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
HL03:
Hierarchical Level
Code
HL04:
Hierarchical Child
Code
135
PAT01:
Individual
Relationship Code
Changed listing of
relationships
LOOP 2010CA:
PATIENT NAME
137
NM101: Entity
Identifier Code
"QC"
NM102: Entity
Type Qualifier
"1"
NM103: Patient
Last Name
NM104: Patient
First Name
NM105: Patient
Middle Name
NM107: Patient
Name Suffix
139
N301: Patient
Address Line
N302: Patient
Address Line
140
N401: Patient City
Name
N402: Patient
State Code
Situational
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
N403: Patient
Postal Zone or
ZIP Code
Situational
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
N404: Patient
Country Code
September 2010
PROMISe™ only
accepts value "19"
Pennsylvania PROMISe™ – 837 Dental Companion
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#
142
144
Field Name
5010 New values, Functions
DMG01: Date
Time Period
Format Qualifier
"D8"
DMG02: Patient
Birth Date
CCYYMMDD
DMG03: Patient
Gender Code
"F", "M", "U"
Description of 5010
Change
REF02: Property
Casualty Claim
Number
PROMISe™ Specific
Instructions
PROMISe™ does not
use the Property and
Casualty Number
Segment
LOOP 2300:
CLAIM
INFORMATION
145
CLM01: Patient
Control Number
CLM02: Total
Claim Charge
Amount
CLM05: - 1
Facility Code
Value
CLM05: - 2
Facility Code
Qualifier
"B"
Data Sub-element
Added
"A", "C"
Now indicates whether
the provider accepts
assignment of benefits
or has a participation
agreement with the
payer or if the provider
does not accept
assignment of benefits
or does not have a
participation
agreement with the
payer
CLM05: - 3 Claim
Frequency Code
CLM06: Provider
or Supplier
Signature
Indicator
CLM07: Provider
Accept
Assignment Code
September 2010
This value should be
"A" for all PROMISe™
enrolled Billing
Providers
Pennsylvania PROMISe™ – 837 Dental Companion
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Page
#
Field Name
5010 New values, Functions
CLM08: Benefits
Assignment
Certification
Indicator
"N", "W", "Y"
CLM09: Release
of Information
Code
"I", "Y"
CLM11: - 1
Related Causes
Code
"AA", "EM", "OA"
CLM11: - 2
Related Causes
Code
"AA", "EM", "OA"
CLM11: - 4 Auto
Accident State or
Province Code
CLM11: - 5
Country Code
CLM12: Special
Program Indicator
"01", "02", "03", "05"
CLM19:
Predetermination
of Benefits Code
"PB"
CLM20: Delay
Reason Code
152
DTP01: Date
Time Qualifier
"439"
DTP02: Date
Time Period
Format Qualifier
"D8"
DTP03: Accident
Date
153
DTP01: Date
Time Qualifier
"452"
DTP02: Date
Time Period
Format Qualifier
"D8"
DTP03:
Orthodontic
Banding Date
September 2010
Description of 5010
Change
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
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#
154
Field Name
5010 New values, Functions
DTP01: Date
Time Qualifier
"472"
DTP02: Date
Time Period
Format Qualifier
"D8", "RD8"
Description of 5010
Change
PROMISe™ Specific
Instructions
DTP03: Service
Date
155
156
DTP Repricer
Receive Date
DN101:
Orthodontic
Treatment Months
Count
"050"
Segment Added
The only allowed value for
DN104 is “Y”, which
indicates that services
reported on this claim are for
orthodontic purposes and that
both DN101 and DN102
were not submitted
Data Element Usage
Change from Not Used
to Situational
DN102:
Orthodontic
Treatment Months
Remaining Count
DN104:
Orthodontic
Treatment
Indicator
158
DN201: Tooth
Number
DN202: Tooth
Status Code
159
PWK01:
Attachment
Report Type Code
PWK02:
Attachment
Transmission
Code
PWK05:
Identification
Code Qualifier
PWK06:
Attachment
Control Number
September 2010
"E", "M"
PROMISe™ will not
use this segment
Pennsylvania PROMISe™ – 837 Dental Companion
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#
162
164
Field Name
CN101: Contract
Type Code
5010 New values, Functions
"02", "03", "04", "05", "06",
"09"
CN102: Monetary
Amount
Segment Added
CN103: Contract
Percentage
Segment Added
CN104: Contract
Code
Segment Added
CN105: Terms
Discount
Percentage
Segment Added
CN106: Contract
Version Identifier
Segment Added
AMT01: Amount
Qualifier Code
"F5"
AMT02: Patient
Amount Paid
165
REF01: Reference
Identification
Qualifier
REF01: Reference
Identification
Qualifier
September 2010
This Segment in 4010
was to be sent at the
service line level or
claim level, but not
both. Now in 5010 it
is to be sent at the
claim level if the
recipient paid any
amount toward the
claim
This Segment in 4010
was to be sent at the
service line level or
claim level, but not
both. Now in 5010 it
is to be sent at the
claim level if the
recipient paid any
amount toward the
claim
"G3"
REF02:
Predetermination
of Benefits
Identifier
166
Description of 5010
Change
Segment Added
"4N"
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
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Page
#
168
Field Name
5010 New values, Functions
REF02: Service
Authorization
Exception Code
"1", "2", "3", "4", "5", "6",
"7"
REF01: Reference
Identification
Qualifier
"F8"
Description of 5010
Change
REF02: Payer
Claim Control
Number
169
REF01: Reference
Identification
Qualifier
This is the location for
original PROMISe™
ICN when voiding to
correcting a previously
submitted claim or
encounter
"9F"
REF02: Referral
Number
171
REF01: Reference
Identification
Qualifier
PROMISe™ Specific
Instructions
This is the location for
Referral Codes
"G1"
REF02: Prior
Authorization
Number
This is the location for
Prior Authorization
Numbers
173
REF: Repriced
Claim Reference
Number
Segment Added
PROMISe™ will not
use this segment
174
REF02: Adjusted
Repriced Claim
Reference
Number
Segment Added
PROMISe™ will not
use this segment
175
REF02: Value
Added Network
Trace Number
177
K301: Fixed
Format
Information
179
NTE01: Note
Reference Code
NTE02: Claim
Note Text
September 2010
PROMISe™ does not
use this segment
Segment Added
Stored only when
qualifier = "ADD"
Pennsylvania PROMISe™ – 837 Dental Companion
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180
Field Name
5010 New values, Functions
HI01: - Health
Care Code
Information
HI01-1: Code List
Qualifier Code
"BK", "ABK"
Description of 5010
Change
Segment Added
Segment Added
HI01-2: Principal
Diagnosis Code
Segment Added
HI02: - Health
Care Code
Information
Segment Added
HI02-1: Code List
Qualifier Code
"BF", "ABF"
Segment Added
HI02-2: Diagnosis
Code
Segment Added
HI03: - Health
Care Code
Information
Segment Added
HI03-1 : Code
List Qualifier
Code
"BF", "ABF"
Segment Added
HI03-2: Diagnosis
Code
Segment Added
HI04: - Health
Care Code
Information
Segment Added
September 2010
PROMISe™ Specific
Instructions
Providers must not send
ICD10 Diagnosis Codes
until mandated date.
Providers must not mix
ICD9 and ICD10
Diagnosis Codes in the
same claim.
Providers must not send
ICD10 Diagnosis Codes
until mandated date.
Providers must not mix
ICD9 and ICD10
Diagnosis Codes in the
same claim.
Providers must not send
ICD10 Diagnosis Codes
until mandated date.
Providers must not mix
ICD9 and ICD10
Diagnosis Codes in the
same claim.
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
HI04-1: Code List
Qualifier Code
185
5010 New values, Functions
"BF", "ABF"
Description of 5010
Change
Segment Added
HI04-2: Diagnosis
Code
Segment Added
HCP01: Repricer
Information
Segment Added
LOOP 2310A:
Referring
Provider Name
190
NM101 Entity
Identifier Code
"DN", "P3"
NM102 Entity
Type Qualifier
"1", "2"
NM103: Referring
Provider Last
Name
NM104: Referring
Provider First
Name
NM105: Referring
Provider Middle
Name
NM107: Referring
Provider Name
Suffix
NM108:
Identification
Code Qualifier
"XX"
NM109 Referring
Provider Identifier
193
Only NPI May be used
as Primary Identifier
PRV01: Provider
Code
"RF"
PRV02: Reference
Identification
Qualifier
"PXC"
September 2010
Only NPI May be used
as Primary Identifier
Changed qualifier for
Taxonomy Codes
PROMISe™ Specific
Instructions
Providers must not send
ICD10 Diagnosis Codes
until mandated date.
Providers must not mix
ICD9 and ICD10
Diagnosis Codes in the
same claim.
PROMISe™ will not
use this segment
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
PRV03: Provider
Taxonomy Code
194
REF01: Reference
Identification
Qualifier
"0B", "1G", "G2"
List of allowed
qualifiers changed
REF02: Referring
Provider
Secondary
Identifier
LOOP 2310B:
Rendering
Provider Name
196
NM101:
"82"
Entity Identifier
Code
NM102: Entity
Type Qualifier
"1", "2"
NM103:
Rendering
Provider Last or
Organization
Name
NM104
Rendering
Provider First
Name
NM105:
Rendering
Provider Middle
Name
NM107:
Rendering
Provider Name
Suffix
NM108:
Identification
Code Qualifier
"XX"
NM109:
Rendering
Provider Identifier
199
PRV01: Provider
Code
September 2010
Only NPI May be used
as Primary Identifier
Usage changed from
required to situational.
"PE"
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Description of 5010
Change
Changed qualifier for
Taxonomy Codes
PROMISe™ Specific
Instructions
PROMISe™ needs the
Taxonomy Code for all
provider entities who
have a Taxonomy
Segment
"0B", "1G", "G2", "LU"
List of allowed
qualifiers changed
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
NM101: Entity
Identifier Code
"77"
Qualifier Change
NM102: Entity
Type Qualifier
"2"
Field Name
PRV02: Reference
Identification
Qualifier
5010 New values, Functions
"PXC"
PRV03: Provider
Taxonomy Code
200
REF01: Reference
Identification
Qualifier
REF02: Rendering
Provider
Secondary
Identifier
LOOP 2310C:
Service Facility
Location Name
202
NM103:
Laboratory or
Facility Name
205
206
NM108:
Identification
Code Qualifier
"XX"
Situational
Only NPI May be used
as Primary Identifier
NM109:
Laboratory or
Facility Primary
Identifier
Situational
Usage changed from
required to situational.
N301: Facility
Address Line
Segment Added
N302: Facility
Address Line
Segment Added
N401: Facility
City Name
Segment Added
N402: Facility
State or Province
Code
Segment Added
September 2010
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
N403: Facility
Postal Zone or
ZIP Code
N404: Facility
Country Code
208
Description of 5010
Change
Segment Added
Segment Added
PROMISe™ needs the
zip code and extension
for all provider entities
who have an address
segment.
"0B", "1G", "G2", "LU"
List of allowed
qualifiers changed
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
NM101: Entity
Identifier Code
"DD"
New Loop Added
NM102: Entity
Type Qualifier
1
New Loop Added
REF01: Reference
Identification
Qualifier
REF02: Facility
Secondary
Identifier
LOOP 2310D:
Assistant Surgeon
Name
210
NM103: Assistant
Surgeon Last
Name
New Loop Added
NM104: Assistant
Surgeon First
Name
New Loop Added
NM105: Assistant
Surgeon Middle
Name
New Loop Added
NM107: Assistant
Surgeon Name
Suffix
New Loop Added
NM108:
Identification
Code Qualifier
"XX"
NM109: Assistant
Surgeon Primary
Identifier
213
PROMISe™ Specific
Instructions
PRV01: Provider
Code
September 2010
New Loop Added
New Loop Added
"AS"
New Loop Added
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
PRV02: Reference
Identification
Qualifier
5010 New values, Functions
"PXC"
PRV03: Provider
Taxonomy Code
214
REF01: Reference
Identification
Qualifier
Description of 5010
Change
New Loop Added
New Loop Added
"0B", "1G", "LU", "G2"
REF02: Assistant
Surgeon
Secondary
Identifier
New Loop Added
New Loop Added
LOOP 2310E:
Supervising
Provider Name
216
NM101: Entity
Identifier Code
"DQ"
New Loop Added
NM102: Entity
Type Qualifier
"1"
New Loop Added
NM103:
Supervising
Provider Last
Name
New Loop Added
NM104:
Supervising
Provider First
Name
New Loop Added
NM105:
Supervising
Provider Middle
Name
New Loop Added
NM107:
Supervising
Provider Name
Suffix
New Loop Added
NM108:
Identification
Code Qualifier
NM109:
Supervising
Provider Identifier
September 2010
PROMISe™ Specific
Instructions
PROMISe™ needs the
Taxonomy Code for all
provider entities who
have a Taxonomy
Segment
"XX"
New Loop Added
New Loop Added
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
219
Field Name
REF01: Reference
Identification
Qualifier
REF02:
Supervising
Provider
Secondary
Identifier
5010 New values, Functions
"0B", "1G", "LU", "G2"
Description of 5010
Change
New Loop Added
New Loop Added
LOOP 2320:
Other Subscriber
Information
221
SBR01: Payer
Responsibility
Sequence Number
Code
New Listing of Payer
Ordering up to 11
distinct payers
SBR02: Individual
Relationship Code
List of allowed
qualifiers changed
SBR03: Insured
Group or Policy
Number
SBR04: Other
Insured Group
Name
SBR05: Insurance
Type Code
SBR09: Claim
Filing Indicator
Code
September 2010
Usage changed from
not used to situational
Used only when
Medicare is the Payer
in this Loop.
"Required when the
payer identified in
Loop ID-2330B for
this iteration of Loop
ID-2320 is Medicare
and Medicare is not
the primary payer
(Loop ID-2320 SBR01
is not P). If not
required by this
implementation guide,
do not send"
PROMISe™ Specific
Instructions
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
225
Field Name
CAS01: Claim
Adjustment Group
Code
CAS02:
Adjustment
Reason Code
CAS03:
Adjustment
Amount
CAS04:
Adjustment
Quantity
CAS05:
Adjustment
Reason Code
CAS06:
Adjustment
Amount
CAS07:
Adjustment
Quantity
CAS08:
Adjustment
Reason Code
CAS09:
Adjustment
Amount
CAS10:
Adjustment
Quantity
CAS11:
Adjustment
Reason Code
CAS12:
Adjustment
Amount
CAS13:
Adjustment
Quantity
CAS14:
Adjustment
Reason Code
September 2010
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
Description of 5010
Change
CAS15:
Adjustment
Amount
CAS16:
Adjustment
Quantity
CAS17:
Adjustment
Reason Code
CAS18:
Adjustment
Amount
CAS19:
Adjustment
Quantity
231
AMT01: Amount
Qualifier Code
"D"
AMT02: Payer
Paid Amount
232
AMT01: Amount
Qualifier Code
AMT02:
Remaining Patient
Liability
September 2010
"EAF"
Segment Added
Required when the
destination payer’s
cost avoidance policy
allows providers to
bypass claim
submission to the
otherwise prior payer
identified in loop ID2330B. If not required
by this implementation
guide, do not send
Segment Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
233
Field Name
AMT01: Amount
Qualifier Code
5010 New values, Functions
"A8"
AMT02: NonCovered Charge
Amount
234
OI03: Benefits
Assignment
Certification
Indicator
Description of 5010
Change
Segment Added
Required when the
destination payer’s
cost avoidance policy
allows providers to
bypass claim
submission to the
otherwise prior payer
identified in loop ID2330B. If not required
by this implementation
guide, do not send
Segment Added
"N", "W", "Y"
Added qualifier W
OI06: Release of
Information Code
"I", "Y"
Changed values and
clarification of usage
rules
MOA01:
Reimbursement
Rate
To convey claim-level data
related to the adjudication of
Medicare claims not related
to an inpatient setting
Segment Added
OI04: Patient
Signature Source
Code
236
MOA02: HCPCS
Payable Amount
Segment Added
MOA03: Claim
Payment Remark
Code
Remittance Advice Remarks
Codes from the Medicare
835
Segment Added
MOA04: Claim
Payment Remark
Code
Remittance Advice Remarks
Codes from the Medicare
835
Segment Added
MOA05: Claim
Payment Remark
Code
Remittance Advice Remarks
Codes from the Medicare
835
Segment Added
MOA06: Claim
Payment Remark
Code
Remittance Advice Remarks
Codes from the Medicare
835
Segment Added
September 2010
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
MOA07: Claim
Payment Remark
Code
Remittance Advice Remarks
Codes from the Medicare
835
MOA08:
Monetary Amount
Not Used
MOA09: NonPayable
Professional
Component Billed
Amount
NM101: Entity
Identifier Code
NM102: Entity
Type Qualifier
NM103: Other
Insured Last
Name
NM104: Other
Insured First
Name
NM105: Other
Insured Middle
Name
NM107: Other
Insured Name
Suffix
NM108:
Identification
Code Qualifier
NM109: Other
Insured Identifier
242
N301: Other
Insured Address
Line
N302: Other
Insured Address
Line
September 2010
Segment Added, but
this data element is
"Not Used" in Dental
Segment Added
LOOP 2330A:
Other Subscriber
Name
239
Description of 5010
Change
Segment Added
"IL"
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
243
Field Name
5010 New values, Functions
Description of 5010
Change
N401: Other
Insured City
Name
N402: Other
Insured State
Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
N403: Other
Insured Postal
Zone or ZIP Code
Usage changed from
required to situational.
However, the note still
requires this data
element to be sent.
N404: Other
Insured Country
245
REF01: Reference
Identification
Qualifier
"SY"
REF02: Other
Insured
Additional
Identifier
LOOP 2330B:
Other Payer Name
246
NM101: Entity
Identifier Code
"PR"
NM102: Entity
Type Qualifier
"2"
NM103: Other
Payer Last or
Organization
Name
NM108:
Identification
Code Qualifier
"PI", "XV"
NM109: Other
Payer Primary
Identifier
248
N301: Other
Payer Address
Line
September 2010
Segment Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
N302: Other
Payer Address
Line
249
251
Description of 5010
Change
Segment Added
N401: Other
Payer City Name
Segment Added
N402: Other
Payer State Code
Segment Added
N403: Other
Payer Postal Zone
or ZIP Code
Segment Added
N404: Other
Payers Country
Segment Added
DTP01: Date
Time Qualifier
“573”
DTP02: Date
Time Period
Format Qualifier
“D8”
DTP03:
Adjudication or
Payment Date
252
REF01: Reference
Identification
Qualifier
"2U", "FY", "NF", "EI"
Allowed qualifiers list
changed.
"G1"
New Segment Added
REF02: Other
Payer Secondary
Identifier
254
REF01: Reference
Identification
Qualifier
REF02: Other
Payer Prior
Authorization
Number
255
REF01: Reference
Identification
Qualifier
REF02: Other
Payer Referral
Number
September 2010
New Segment Added
"9F"
New Segment Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
256
Field Name
REF01: Reference
Identification
Qualifier
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
"T4"
REF02: Other
Payer Claim
Adjustment
Indicator
257
REF01: Reference
Identification
Qualifier
"G3"
REF02: Other
Payer
Predetermination
of Benefits
Identifier
258
REF01: Reference
Identification
Qualifier
New Segment Added
"F8"
REF02: Other
Payer's Claim
Control Number
261
NM101: Entity
Identifier Code
"DN", "P3"
NM102: Entity
Type Qualifier
"1"
REF01: Reference
Identification
Qualifier
"0B", "1G", "G2"
REF02: Other
Payer Referring
Secondary
Provider Identifier
LOOP 2330D:
Other Payer
Rendering
Provider
263
NM101: Entity
Identifier Code
September 2010
New Segment Added
New Segment Added
LOOP 2330C:
Other Payer
Referring
Provider
259
New Segment Added
"82"
MCO ICN for
Encounters
Medicare ICN for
Crossovers
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
265
Field Name
5010 New values, Functions
NM102: Entity
Type Qualifier
"1"
REF01: Reference
Identification
Qualifier
"0B", "1G", "G2"
Description of 5010
Change
REF02: Other
Payer Rendering
Provider
Secondary
Identifier
LOOP 2330E:
Other Payer
Supervising
Provider
267
269
NM101: Entity
Identifier Code
"DQ"
New Loop Added
NM102: Entity
Type Qualifier
"1"
New Loop Added
REF01: Reference
Identification
Qualifier
"0B", "1G", "LU", "G2"
New Loop Added
REF02: Other
Payer Supervising
Provider Identifier
New Loop Added
LOOP 2330F:
Other Payer
Billing Provider
271
273
NM101: Entity
Identifier Code
"85"
New Loop Added
NM102: Entity
Type Qualifier
"1", "2"
New Loop Added
REF01: Reference
Identification
Qualifier
"G2", "LU"
New Loop Added
REF02: Other
Payer Billing
Provider
Secondary
Identifier
September 2010
New Loop Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
Description of 5010
Change
LOOP 2330G:
Other Payer
Service Facility
Location
274
NM101: Entity
Identifier Code
"77"
New Loop Added
NM102: Entity
Type Qualifier
"2"
New Loop Added
REF01: Reference
Identification
Qualifier
"0B", "LU", "G2"
New Loop Added
REF02: Other
Payer Service
Facility Location
Identifier
New Loop Added
LOOP 2330H:
Other Payer
Assistant Surgeon
277
279
NM101: Entity
Identifier Code
"DD"
New Loop Added
NM102: Entity
Type Qualifier
"1", "2"
New Loop Added
REF01: Reference
Identification
Qualifier
"0B, "1G", "LU", "G2"
New Loop Added
REF02: Other
Payer Assistant
Surgeon
Secondary
Identification
LOOP 2400:
Service Line
Number
281
LX01: Assigned
Number
282
SV301 – 1:
Product or Service
ID Qualifier
SV301 – 2:
Procedure Code
September 2010
New Loop Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
Description of 5010
Change
SV301: 3:
Procedure
Modifier
SV301: 4:
Procedure
Modifier
SV301: 5:
Procedure
Modifier
SV301: 6:
Procedure
Modifier
SVC301: 7:
Procedure Code
Description
Situational
SV302: Line Item
Charge Amount
SV303: Place of
Service Code
SV304: 1 Oral
Cavity
Designation Code
SV304: 2 Oral
Cavity
Designation Code
SV304: 3 Oral
Cavity
Designation Code
SV304: 4 Oral
Cavity
Designation Code
SV304: 5 Oral
Cavity
Designation Code
SV305:
Prosthesis,
Crown, or Inlay
Code
SV306: Procedure
Count
September 2010
"I", "R"
Added description to
procedure code
composite data
element
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
SV311:
Composite
Diagnosis Code
Pointer
288
Description of 5010
Change
This first pointer
designates the primary
diagnosis for this
service line.
Remaining diagnosis
pointers indicate
declining level of
importance to service
line. Acceptable values
are 1 through 4, and
correspond to
Composite Data
Elements 01 through
04 in the Health Care
Diagnosis Code HI
segment in the Claim
Loop ID-2300
SV311-1:
Diagnosis Code
Pointer
New composite data
element added
SV311-2:
Diagnosis Code
Pointer
New composite data
element added
SV311-3:
Diagnosis Code
Pointer
New composite data
element added
SV311-4:
Diagnosis Code
Pointer
New composite data
element added
TOO01: Code List
Qualifier Code
TOO02: Tooth
Code
TOO03: 1 Tooth
Surface Code
TOO03: 2: Tooth
Surface Code
TOO03: 3: Tooth
Surface Code
TOO03: 4: Tooth
Surface Code
TOO03: 5: Tooth
Surface Code
September 2010
“JP”
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
290
Field Name
5010 New values, Functions
DTP01: Date
Time Qualifier
“472”
DTP02: Date
Time Period
Format Qualifier
“D8”
Description of 5010
Change
DTP03: Service
Date
291
DTP01: Date
Time Qualifier
“139”, “441”
DTP02: Date
Time Period
Format Qualifier
“D8”
DTP03: Prior
Placement Date
292
DTP01: Date
Time Qualifier
“452”
DTP02: Date
Time Period
Format Qualifier
“D8”
DTP03:
Orthodontic
Banding Date
293
DTP01: Date
Time Qualifier
“446”
DTP02: Date
Time Period
Format Qualifier
“D8”
DTP03:
Replacement Date
294
DTP01: Date
Time Qualifier
"196"
New Segment Added
DTP02: Date
Time Period
Format Qualifier
"D8"
New Segment Added
DTP03: Treatment
Start Date
295
DTP01: Date
Time Qualifier
September 2010
New Segment Added
"198"
New Segment Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
DTP02: Date
Time Period
Format Qualifier
5010 New values, Functions
"D8"
DTP03: Treatment
Completion Date
296
298
CN101: Contract
Type Code
Description of 5010
Change
New Segment Added
New Segment Added
"02", "03", "04", "05", "06",
"09"
Segment Added
CN102: Contract
Amount
Segment Added
CN103: Contract
Percentage
Segment Added
CN104: Contract
Code
Segment Added
CN105: Terms
Discount
Percentage
Segment Added
CN106: Contract
Version Identifier
Segment Added
REF01: Reference
Identification
Qualifier
PROMISe™ Specific
Instructions
"G3"
REF02:
Predetermination
of Benefits
Identifier
300
REF01: Reference
Identification
Qualifier
"G1"
REF02: Prior
Authorization
Number
302
REF01: Reference
Identification
Qualifier
“6R”
REF02: Line Item
Control Number
304
REF: Repriced
Claim Reference
Number
September 2010
Segment Added
PROMISe™ will not
use this segment
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
305
306
Field Name
5010 New values, Functions
REF: Adjusted
Repriced Claim
Reference
Number
REF01: Reference
Identification
Qualifier
Description of 5010
Change
Segment Added
PROMISe™ Specific
Instructions
PROMISe™ will not
use this segment
"9F"
REF02: Referral
Number
308
AMT01: Amount
Qualifier Code
“T”
AMT01: Sales
Tax Amount
309
K301: Fixed
Format
Information
Segment Added
311
HCP Repricer
Information
Segment Added
LOOP 2420A:
Rendering
Provider Name
316
NM101: Entity
Identifier Code
NM102: Entity
Type Qualifier
NM103:
Rendering
Provider Last or
Organization
Name
NM104:
Rendering
Provider First
Name
NM105:
Rendering
Provider Middle
Name
NM107:
Rendering
Provider Name
Suffix
September 2010
"82"
PROMISe™ will not
use this segment
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
NM108:
Identification
Code Qualifier
5010 New values, Functions
"XX"
NM109:
Rendering
Provider Identifier
319
Description of 5010
Change
Changed from required
to situational. Can
only be sent if the
Provider primary ID is
an NPI
PROMISe™ Specific
Instructions
Changed from required
to situational. Can
only be sent if the
Provider primary ID is
an NPI
PRV01: Provider
Code
"PE"
PRV02: Reference
Identification
Qualifier
"PXC"
Changed qualifier for
Taxonomy Codes
PROMISe™ needs
taxonomy codes for all
provider entities who
have a taxonomy code
"0B", "1G", "G2", "LU"
List of allowed
qualifiers changed
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
NM101: Entity
Identifier Code
"DD"
New Loop Added
NM102: Entity
Type Qualifier
"1"
New Loop Added
PRV03: Provider
Taxonomy Code
320
REF01: Reference
Identification
Qualifier
REF02: Rendering
Provider
Secondary
Identifier
LOOP 2420B:
Assistant Surgeon
Name
322
NM103: Assistant
Surgeon Last or
Organization
Name
New Loop Added
NM104: Assistant
Surgeon First
Name
New Loop Added
NM105: Assistant
Surgeon Middle
Name
New Loop Added
September 2010
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
NM107: Assistant
Surgeon Name
Suffix
325
NM108:
Identification
Code Qualifier
"XX"
Situational
New Loop Added
NM109: Assistant
Surgeon Primary
Identifier
Situational
New Loop Added
PRV01: Provider
Code
PRV02: Reference
Identification
Qualifier
REF01: Reference
Identification
Qualifier
"PXC"
New Loop Added
"0B", "1G", "G2", "LU"
New Loop Added
New Loop Added
LOOP 2420C:
Supervising
Provider Name
NM101: Entity
Identifier Code
"DQ"
New Loop Added
NM102: Entity
Type Qualifier
"1"
New Loop Added
NM103:
Supervising
Provider Last
Name or
Organizational
Name
New Loop Added
NM104:
Supervising
Provider First
Name
New Loop Added
September 2010
PROMISe™ needs
taxonomy codes for all
provider entities who
have a taxonomy code
New Loop Added
REF02: Assistant
Surgeon
Secondary
Identifier
328
PROMISe™ Specific
Instructions
New Loop Added
PRV03: Provider
Taxonomy Code
326
Description of 5010
Change
New Loop Added
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
NM105:
Supervising
Provider Middle
Name or Initial
NM017:
Supervising
Provider Name
Suffix
NM108:
Identification
Code Qualifier
REF01: Reference
Identification
Qualifier
"XX"
New Loop Added
New Loop Added
"0B", "1G", "G2", "LU"
REF02:
Supervising
Provider
Secondary
Identifier
New Loop Added
New Loop Added
LOOP: 2420D
Service Facility
Location
333
NM101: Entity
Identifier Code
"77"
New Loop Added
NM102: Entity
Type Qualifier
"2"
New Loop Added
NM103:
Laboratory or
Facility Name
NM108:
Identification
Code Qualifier
336
New Loop Added
"XX"
New Loop Added
NM109:
Laboratory or
Facility Primary
Identifier
New Loop Added
N301: Laboratory
or Facility
Address Line
New Loop Added
September 2010
PROMISe™ Specific
Instructions
New Loop Added
NM109:
Supervising
Provider Identifier
331
Description of 5010
Change
New Loop Added
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
N302: Laboratory
or Facility
Address Line
337
339
N401: Laboratory
or Facility City
Name
New Loop Added
N402: Laboratory
or Facility State or
Province Code
New Loop Added
N403: Laboratory
or Facility Postal
Zone or ZIP Code
New Loop Added
N404: Laboratory
or Facility
Country Code
New Loop Added
REF01: Reference
Identification
Qualifier
REF02: Service
Facility Location
Secondary
Identifier
Line Adjudication
Information
341
Description of 5010
Change
New Loop Added
SVD01: Other
Payer Primary
Identifier
SVD02: Service
Line Paid Amount
SVD03: 1 Product
or Service ID
Qualifier
SVD03: 2
Procedure Code
SVD03: 3
Procedure
Modifier
SVD03: 4
Procedure
Modifier
September 2010
"1G", "G2", "LU"
New Loop Added
New Loop Added
PROMISe™ Specific
Instructions
G2 Qualifier here means
PROMISe™ Legacy
(MAID) Identifier
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
SVD03: 5
Procedure
Modifier
SVD03: 6
Procedure
Modifier
SVD03: 7
Procedure Code
Description
SVD05: Paid
Service Unit
Count
SVD06: Bundled
or Unbundled
Line Number
345
CAS01:
Adjustment Group
Code
CAS02:
Adjustment
Reason Code
CAS03:
Adjustment
Amount
CAS04:
Adjustment
Quantity
CAS05:
Adjustment
Reason Code
CAS06:
Adjustment
Amount
CAS07:
Adjustment
Quantity
CAS08:
Adjustment
Reason Code
CAS09:
Adjustment
Amount
September 2010
5010 New values, Functions
Description of 5010
Change
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
5010 New values, Functions
Description of 5010
Change
CAS10:
Adjustment
Quantity
CAS11:
Adjustment
Reason Code
CAS12:
Adjustment
Amount
CAS13:
Adjustment
Quantity
CAS14:
Adjustment
Reason Code
CAS15:
Adjustment
Amount
CAS16:
Adjustment
Quantity
CAS17:
Adjustment
Reason Code
CAS18:
Adjustment
Amount
CAS19:
Adjustment
Quantity
351
DTP01: Date
Time Qualifier
“573’
DTP02: Date
Time Period
Format Qualifier
“D8”
DTP03:
Adjudication or
Payment Date
352
AMT01: Amount
Qualifier Code
September 2010
"EAF"
New Segment Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion
Guide
Page
#
Field Name
AMT02:
Remaining Patient
Liability Amount
SE01: Transaction
Segment Count
SE02: Transaction
Set Control
Number
September 2010
5010 New values, Functions
Description of 5010
Change
New Segment Added
PROMISe™ Specific
Instructions
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Appendix A – Insurance Carriers
Insurance Listings with Addresses:
Carrier Code
Carrier Name
100
Medicare Part B
103
Medicare Part D
200
Independence Blue Cross
1901 Market Street
Philadelphia, PA. 19103
201
Highmark Blue Cross/Blue Shield
Fifth Avenue Place
120 Fifth Ave/Suite P3105
Pittsburgh, PA. 15222
202
Capital Blue Cross
2500 Elmerton Avenue
Harrisburg, PA. 17177
203
Blue Cross of N.E. PA
19 N Main Street
Wilkes-Barre, PA. 18711
240
Security 65 Independence
Plan
1901 Market Street
Philadelphia, PA. 19103
241
Security 65 Highmark Plan
5th Avenue Place
Pittsburgh, PA. 15222
242
Security 65 Capital Plan
Dept 778995
Harrisburg, PA. 17177-8995
243
Security 65 Northeast Plan
70 N Main Street
Wilkes-Barre, PA. 18711
244
Highmark Service Company
5th Avenue Place
120 5th Avenue Place/Suite P3105
Pittsburgh, PA. 15222
249
Blue Cross Medigap (out-of-state)
299
Blue Cross Out of State
September 2010
Address
Page 51
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
300
PA Blue Shield
P.O. Box 898206
Camp Hill, PA. 17089-0400
300
PA Blue Shield
P.O. Box 890500
Camp Hill, PA. 17089-0500
300
PA Blue Shield
P.O. Box 890062
Camp Hill, PA. 17089-0062
302
Highmark Blue Shield
P.O. Box 898206
Camp Hill, PA. 17089-8206
302
Highmark Blue Shield
P.O. Box 890173
Camp Hill, PA. 17089-0173
302
Highmark Blue Shield
P.O. Box 890500
Camp Hill, PA. 17089-0500
340
Blue Shield Medigap - Security 65
P.O. Box 898845
Camp Hill, PA. 17089-8845
349
Blue Shield Medigap (out-of-state)
399
Blue Shield Out Of State
400
TRICARE/United Concordia
TDP Claims Processing/PO Box 69411
Harrisburg, PA 17106
400
TRICARE (formerly CHAMPUS)
Palmetto GBA/PO Box 7011
Camden, SC 29020
400
TRICARE/Express Scripts
PO Box 390007
Bloomington, MN 55439
401
ChampVA
PO Box 65023
Denver, CO 80206-9023
401
ChampVA
PO Box 65023
Denver, CO 80206-9023
500
Personal Choice 65/Keystone 65
1901 Market Street
Philadelphia, PA 19103
501
Freedom Blue
120 Fifth Ave, Suite P5501
Pittsburgh, PA 15222
September 2010
Page 52
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
502
Capital SeniorBlue
2500 Elmerton Ave
Harrisburg, PA 17177
503
Senior Partners Terminated 7/31/07
now 516
PO Box 5194
New York, NY 10004-5194
504
SecurityBlue
120 Fifth Ave, Suite P5501
Pittsburgh, PA 15222
505
Aetna
151 Farmington Avenue
Hartford, CT 06156
506
Gateway Health Plan Medicare
Assured
600 Grant Street, 41st Floor
Pittsburgh, PA 15219
507
Humana
101 East Main Street
Louisville, KY 40202
508
SecureHorizons
13621 NW 12th St, FL075-1000
Sunrise, FL 33323
509
Advantra
11 Stanwix Street, Suite 2300
Pittsburgh, PA 15222
510
Sterling Option 1
2219 Rimland Dr, PO Box 5348
Bellingham, WA 98226
511
Geisinger Health Plan
100 North Academy Avenue
Danville, PA 17822
512
Amerihealth 65
1901 Market Street
Philadelphia, PA 19103
513
Unison Advantage
1001 Brinton Road
Pittsburgh, PA 15221
514
Keystone 65 Complete
1901 Market Street
Philadelphia, PA 19103
515
UPMC For Life
112 Washington Place
Pittsburgh, PA 15219
516
Bravo Health Pennsylvania
3601 O’Donnell Street
Baltimore, MD 21224
517
Today’s Options
4888 Loop Central Dr,
September 2010
Page 53
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
Suite 900
Houston, TX 77081
518
United Healthcare (Evercare)
13621 NW 12th Street
Sunrise, FL 33323
519
Keystone SeniorBlue
2500 Elmerton Avenue
Harrisburg, PA 17177
520
WellCare
8735 Henderson Road
Tampa, FL 33634
521
Horizon Blue Cross Blue Shield of
New Jersey
3 Penn Plaza East
Newark, NJ 07105
522
Healthfirst Medicare Plan
25 Broadway, 9th Floor
New York, NY 10004
523
Trustees of the University of
Pennsylvania
4508 Chestnut Street
Philadelphia, PA 19139
524
Community LIFE
2400 Ardmore Blvd, Suite 700
Pittsburgh, PA 15221
525
LIFE Pittsburgh
875 Greentree Road
One Parkway Ctr, Suite 200
Pittsburgh, PA 15220
526
St Agnes LIFE
1900 South Broad Street
Philadelphia, PA 19145
527
Coventry Healthcare
3721 Tecport Drive
Harrisburg, PA 17106
528
Universal Health Care
150 2nd Ave North, Suite 400
Saint Petersburg, FL 33701
529
Citrus Health Care
5420 Bay Center Dr, Suite 250
Tampa, FL 33609
530
GHI Medicare Choice
441 Ninth Avenue
New York, NY 10001
531
UniCare
PO Box 9154
Oxnard, CA 93031
September 2010
Page 54
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
532
Anthem Blue Cross/Blue Shield
4241 Irwin Simpson Road, OHO205-A037
Mason, OH 45040
533
Care Improvement Plus
250 West Pratt St, Suite 230
Baltimore, MD 21201
534
Life at Home
101 East State Street
Kennett Square, PA 19348
535
Senior LIFE Johnstown
209 Sigma Drive
Pittsburgh, PA 15238
536
USACare
259 Monroe Ave
Rochester, NY 14607
537
HIP Health Plan of Greater New
York
55 Water Street
New York, NY 10041-8190
538
MD MedicareChoice
5501 West Waters Ave, Ste 401
Tampa, FL 33634
539
HealthMarkets Care Assured
9151 Blvd 26
North Richland Hills, TX 76180
540
LIFE LUTHERAN
840 Fifth Avenue
Chambersburg, PA 17201
541
LIFE Beaver County
1323 Freedom Road
Cranberry Twp, PA 16066
542
CIGNA Medicare Access
900 Cottage Grove Road, Hartford, CT 06152
543
Universal American
1001 Heathrow Park Lane, Suite 5001,
Lake Mary, FL 32746
598
Unlisted Medicare Advantage HMO’s
600
Medicare Part A
700
Delta Dental of PA
One Delta Drive
Mechanicsburg, PA 17055
701
Amalgamated Life Insurance Co.
730 Broadway
New York, NY. 10003-9511
September 2010
Page 55
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
702
Aetna Life Insurance Co.
151 Farmington Avenue
Hartford, CT. 06156
703
Allstate Insurance Co.
60 Allstate Plaza S.
Northbrook, IL. 60062
704
Bankers Life & Casualty Co.
222 Merchandise Mart Plaza
Chicago, IL. 60654
705
United Concordia
4401 Deer Path Road
Harrisburg, PA 17110
706
CONSECO
11825 N Pennsylvania St
Carmel, IN 46032
707
Combined Insurance Co. of America
1000 Milwaukee Ave
Glenview, IL 60025
708
CIGNA
900 Cottage Road
Bloomfield, CT 06002
709
Argus
PO Box 419019
Kansas City, MO 64141
710
Continental Casualty Insurance Co.
333 South Wabash
Chicago, IL. 60604
711
American General
70 Pine Street
New York, NY 10270
712
Eastern Life & Health Insurance Co.
25 Race Avenue
Lancaster, PA 17608
713
AXA Equitable Life Insurance Co.
PO Box 1047
Charlotte, NC 28201
714
Inter-Co. Hospital Plan
720 Blair Mill Road
Horsham, PA. 19044
715
Inter-Co. Phys. Service Plan
720 Blair Mill Road
Horsham, PA. 19044
716
John Hancock Mutual Life Insurance P.O. Box 111
Co.
Boston, MA. 02117
718
Life Insurance Co. North America
September 2010
1601 Chestnut Street
Page 56
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
Philadelphia, PA. 19192
719
Lincoln Financial Group
8801 Indian Hills Drive
Omaha, NE 68114
720
Mass Mutual Life Insurance Co.
1295 State Street
Springfield, MA 01111
721
United Healthcare
P O Box 740800
Atlanta, GA 30374
722
Mutual of Omaha Insurance Co.
Mutual Of Omaha Plaza
Omaha, NE. 68175
723
People Benefit Life Insurance Co.
Claims Dept.
Valley Forge, PA. 19493
724
New York Life Insurance Co.
51 Madison Avenue
New York, NY. 10010
725
Transamerica Occidental Insurance
Co.
P.O. Box 2101
Los Angeles, CA. 90051-2101
726
Phoenix Mutual Life Insurance Co.
PO Box 22012
Albany, NY 12201-2012
727
Provident Life/Accident Insurance
Co.
Fountain Square
Chattanooga, TN. 37402
728
Prudential Insurance Co. of America
751 Broad Street
Newark, NJ 07102
730
Travelers Insurance
One Town Square MPB
Hartford, CT 06183
731
National Association of Letter
Carriers
20547 Waverly Court
Ashburn, VA 20149
732
Washington National Insurance Co.
PO Box 2004
Carmel, IN 46032-3004
733
Paid Prescription (MEDCO)
P.O. Box 6121
Fair Lawn, NJ. 07410-0999
734
American Postal Workers Union
PO Box 967
Silver Spring, MD 20910
September 2010
Page 57
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
735
Accordia National
P.O. Box 3262
East Charleston, WV 25332
736
Employers Health Insurance Co.
PO Box 14610
Lexington, KY 40512-4610
737
Jefferson-Pilot Life Insurance Co.
P.O. Box 21008
Greensboro, NC. 27420
738
Philadelphia American Life Ins. Co.
P.O. Box 4884
Houston, TX. 77210
739
Protective Life Insurance Co.
2801 HWY 280 South
Birmingham, AL 35223
740
Commercial Medigap
741
AARP Medigap
PO Box 740819
Atlanta, GA 30374-0819
742
National Vision Administrators
P.O. Box 1981
East Hanover, NJ. 07936-0981
743
Express Scripts
P.O. Box 390007
Bloomington, MN 55439
744
PEBTF
150 S. 43rd Street, Suite 1
Harrisburg, PA. 17111-5700
745
National Pharmaceutical Services
P.O. Box 407
Boystown, NE. 68010
746
Eagle Managed Care
Terminated 12/31/1999
30 Hunter Lane P.O. Box 7011
Camp Hill, PA. 17011
747
PCS
950 E. Shea Blvd.
Scottsdale, AZ. 85260
748
Merck MEDCO
1810 Lincoln Hwy
N Versailles, PA 15127
749
Caremark
PO Box 686005
San Antonio, TX 78268
750
Aetna HMO Health PLS East/Central PO Box 981107
PA
El Paso, TX 79998-1107
September 2010
Page 58
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
751
Americhoice Personal Care Plus
Terminated 7/31/05
PO Box 16000
Phoenix, AZ 85011-6000
752
Alliance Health Network
1700 Peach Street
Erie, PA. 16501
753
Advantage Health Plan PA
121 Seventh Street
Pittsburgh, PA. 15222-3408
754
Cigna Healthcare of PA
P.O. Box 15422 STE CHP
Wilmington, DE. 19803
755
Geisinger Health Plan
PO Box 8200
Danville, PA 17821-8200
756
Unison Advantage (3 Rivers)
Terminated 6/30/06
Use code 513.
PO Box 1018
Monroeville, PA 15146
757
HealthAmerica /Health Assurance
3721 Tecport Drive
PO Box 67103
Harrisburg, PA 17106
758
HealthAmerica /Health Assurance
(Pittsburgh)
PO Box 7088
London, KY 40742
759
Healthguard of Lancaster
Terminated 2/1/2006
280 Granite Run Drive
Lancaster, PA. 17601
760
First Priority Health
19 N. Main Street
Wilkes-Barre, PA. 18711
761
Keystone Health Plan Central
P.O. Box 898812
Camp Hill, PA. 17089-8812
762
Keystone Health Plan East
1901 Market Street
Philadelphia, PA. 19103
763
Keystone Health Plan West
PO Box 898819
Camp Hill, PA 17089
765
Prudential Health Care Plan
P.O. Box 901
Horsham, PA. 19044
766
Healthnet of the Northeast
P.O. Box 14700
Lexington, KY 40512
September 2010
Page 59
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
Address
767
Aetna/US Healthcare Pittsburgh
Terminated 08/12/2005
5313 Campbells Run Road
Pittsburgh, PA. 15205
768
Aetna/US Healthcare/HMO PA
Terminated 08/12/2005
P.O. Box 1109
Blue Bell, PA. 19422
770
Health Partners/Senior Partners of
Philadelphia (Terminated 6/30/06)
Use code 503.
PO Box 5194
New York, NY 10004-5194
771
Horizon Healthcare
Terminated 12/31/2000
1700 Market Street
Philadelphia, PA. 19103
772
HIP Health Plan of PA
6 Neshaminy Interplex
Trevose, PA. 19053
774
UPMC Health Plan Inc
PO Box 2999
Pittsburgh, PA. 15230
775
Optimum Choice Inc of PA
PO Box 930
Frederick, MD 21705
776
Philcare Health Systems
2005 Market Street
Philadelphia, PA. 19103
777
Health Central
Terminated 12/31/2001
2605 Interstate Drive
Harrisburg, PA. 17110
778
Amerihealth HMO
1901 Market Street
Philadelphia, PA 19103
779
Health Plans of PA
100 W Sproul Road - 3Rd Floor
Springfield, PA 19064
780
Principal HealthCare of PA
2751 Centerville Road
Wilmington, DE 19808
781
Avalon Health Ltd.
2500 Elmerton Avenue
Harrisburg, PA 17110
783
Qualmed Plans For Health
1835 Market Street
Philadelphia, PA 19103
784
Physicians Care HMO
651 East Park Drive, Suite 108 Harrisburg, PA
17111
September 2010
Page 60
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Code
Carrier Name
798
Other HMO
799
Commercial Insurance (Not
Otherwise Listed)
801
Auto Insurance Terminated 5/24/07
802
Workers’ Compensation
803
Black Lung Medical Benefits
900
Patient Pay
902
LTC Patient Pay
903
Transfer Penalty
Address
Alphabetical Listing of Insurance Carriers:
Carrier Name
Carrier Code
AARP Medigap
741
Accordia National
735
Advantage Health Plan
753
Advantra (Medicare Advantage)
509
Aetna (Medicare Advantage)
505
Aetna HMO Health Plans East/Central PA
750
Aetna Life Insurance Co
702
Alliance Health Network
752
Allstate Insurance Company
703
Amalgamated Life Insurance Co
701
American General Ins Co
711
September 2010
Page 61
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Name
Carrier Code
American Postal Workers Union
734
Americhoice Personal Care Plus
751
Amerihealth HMO
778
Amerihealth 65
512
Anthem Blue Cross/Blue Shield (Medicare Advantage)
532
Argus
709
Auto Insurance
801
Avalon Health LTD
781
Bankers Life & Casualty Co
704
Black Lung Medical Benefits
803
Blue Cross Medigap (out of state)
249
Blue Cross of Northeastern PA
203
Blue Cross Out-of-State
299
Blue Shield Medigap (out of state)
349
Blue Shield Medigap Security 65
340
Blue Shield Out-of-State
399
Bravo Health Pennsylvania (Medicare Advantage)
516
Capital Blue Cross
202
Capital SeniorBlue (Medicare Advantage)
502
Care Improvement Plus (Medicare Advantage)
533
Caremark
749
Champus (Tricare & United Concordia)
400
September 2010
Page 62
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Name
Carrier Code
Champus/VA
401
CIGNA
708
CIGNA Healthcare of PA
754
CIGNA Medicare Access (Medicare Advantage)
542
Citrus Health Care (Medicare Advantage)
529
Combined Insurance Company of America
707
Commercial Insurance (Carrier name not on list)
799
Commercial Medigap Ins. (Not otherwise listed)
740
Compensation
802
Community LIFE (Medicare Advantage)
524
CONSECO
706
Continental Casualty Ins Co
710
Coventry Healthcare (Medicare Advantage)
527
Delta Dental of PA
700
Educators Mutual Life Ins Co
712
Employers Health Insurance Co
736
Equitable Assurance Soc-US
713
Express Scripts
743
First Priority Health
760
Freedom Blue (Medicare Advantage)
501
Gateway Health Plan Medicare Assured (Medicare Advantage)
506
Geisinger Health Plan
755
September 2010
Page 63
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Name
Carrier Code
Geisinger Health Plan (Medicare Advantage)
511
GHI Medicare Choice (Medicare Advantage)
530
Health Plans of PA
779
HealthAmerica Advantra/Advantra Gold/Advantra Silver (Medicare Advantage)
509
HealthAmerica/Health Assurance
757
HealthAmerica/Health Assurance (Pittsburgh)
758
Healthfirst Medicare Plan (Medicare Advantage)
522
Healthguard of Lancaster
759
HealthMarkets Care Assured (Medicare Advantage)
539
Healthnet of the Northeast
766
Highmark Blue Cross/Blue Shield
201
Highmark Blue Shield
302
Highmark Service Company
244
HIP Health Plan of Greater New York (Medicare Advantage)
537
HIP Health Plan of PA
772
Horizon BC/BS of New Jersey (Medicare Advantage)
521
Humana (Medicare Advantage)
507
Independence Blue Cross
200
Inter-County Hosp Plan
714
Inter-County Phys Serv Plan
715
Jefferson-Pilot Life Ins Co
737
John Hancock Mutual Life Ins Co
716
September 2010
Page 64
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Name
Carrier Code
Keystone 65 Complete (Medicare Advantage)
514
Keystone Health Plan Central
761
Keystone Health Plan East
762
Keystone Health Plan West
763
Keystone SeniorBlue (Medicare Advantage)
519
Life Insurance Co North America
718
LIFE at Home (Medicare Advantage)
534
LIFE Beaver County (Medicare Advantage)
541
LIFE LUTHERAN (Medicare Advantage)
540
LIFE Pittsburgh (Medicare Advantage)
525
Lincoln National Life Ins Co
719
Long Term Care Patient Pay
902
MD MedicareChoice (Medicare Advantage)
538
Massachusetts Mutual Life Ins Co
720
Medicare A
600
Medicare B
100
Merck MEDCO
748
Mutual of Omaha Ins Co
722
National Association of Letter Carriers
731
National Pharmaceutical Svc
745
National Vision Administrators
742
New York Life Insurance Co
724
September 2010
Page 65
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Name
Carrier Code
Optimum Choice Inc of PA
775
Other HMO(Must enter name/address)
798
Paid Prescription (Medco)
733
PCS
747
PEBTF(Major Med /Medigap)
744
Pennsylvania Blue Shield (associated with a Blue Cross Plan)
300
People Benefit Life Insurance Company
723
Personal Choice 65/Keystone 65 (Medicare Advantage)
500
Philadelphia American Life Ins
738
Philcare Health Systems
776
Phoenix Mutual Life Ins Co
726
Physicians Care HMO
784
Principal Health Care of PA
780
Protective Life Ins Co
739
Provident Life & Accident Ins
727
Prudential Health Care Plan
765
Prudential Ins Co of America
728
Qualmed Plans for Health
783
St Agnes LIFE (Medicare Advantage)
526
SecureHorizons (Medicare Advantage)
508
Security 65 Capital Plan
242
Security 65 Highmark Plan
241
September 2010
Page 66
Pennsylvania PROMISe™ – 837 Dental Companion Guide
Carrier Name
Carrier Code
Security 65 Independence Plan
240
Security 65 Northeast Plan
243
Security Blue (Medicare Advantage)
504
Senior LIFE Johnstown (Medicare Advantage)
535
Senior Partners (Medicare Advantage)
503
Sterling Option 1 (Medicare Advantage)
510
Today’s Option (Medicare Advantage)
517
Transamerica Occidental Ins Co
725
Trustees of the University of Pennsylvania (Medicare Advantage)
523
UniCare (Medicare Advantage)
531
Unison Advantage (Medicare Advantage)
513
United Concordia
705
United Health Care
721
United HealthCare (Evercare/Erickson Advantage) (Medicare Advantage)
518
Universal American (Medicare Advantage)
543
Universal Health Care (Medicare Advantage)
528
UPMC For Life (Medicare Advantage)
515
UPMC Health Plan
774
USACare (Medicare Advantage)
536
Washington National Ins Co
732
WellCare (Medicare Advantage)
520
September 2010
Page 67