Institutional

IG Page	Loop	Segment	Data Element	Usage	Valid Options	Gateway Comments
77	2010AA	NM1	NM108-Identification Code Qualifier	Required	Use '"24" or "34", XX=NPI	Gateway Health Plan Prefers "XX"
77	2010AA	NM1	NM109-Identification Code	Required	24: Tax Identification Number or 34: Social Security Number of facility or billing provider, XX=NPI	The provider NPI number related to the billing entity or group provider should be entered here.
82	2010AA	REF	REF01-Reference Identification Qualification	Required	Use "0B" or "1D" or "G2"
82	2010AA	REF	REF02- Reference Identification Code	Required	0B: State Medicaid Number 1D: Medicaid Provider Number G2: Provider Commercial Number	Gateway Health Plan prefers "G2". The provider number related to the billing entity or group should be entered here.
108	2010BA	NM1	NM108-Identification Code Qualifier	Situational	Use "MI"
108	2010BA	NM1	NM109-Identification Code	Situational	Valid Member Identification Numbers: Gateway Health Plan Member Number (8 digits) Medicaid Recipient Number (10 digits)	Gateway Health Plan recommends using the 8 digit member number in NM109 including leading zeros. Since subscriber is always the same as the patient, Gateway Health Plan does not require Loop 2000C, Patient Information to be populated
115	2010BA	DMG01	Date/Time Period Qualifier	Required	Use "D8"	Required since all GHP's subscriber will always be the same as the patient
115	2010BA	DMG02	Subscriber Birth Date	Required	CCYYMMDD	Gateway Health Plan requires this information to properly identify a member
227	2300	HI01-1	Diagnosis Type Code	Required	"BK" for Principal Diagnosis Codes
227	2300	HI01-2	Diagnosis Code	Required	Valid Principal Diagnosis Codes	Gateway Health Plan only accepts valid ICD-9 Diagnosis Codes and will status back any claims with codes that are not valid
227	2300	HI02-1	Diagnosis Type Code	Required	"BJ" for the Admitting Diagnosis Codes
227	2300	HI02-2	Diagnosis Code	Required	Valid Admitting Diagnosis Codes	Gateway Health Plan only accepts valid ICD-9 Diagnosis Codes and will status back any claims with codes that are not valid
227	2300	HI03-1	Diagnosis Type Code	Required	"BN" for External Causes of Injury Code
227	2300	HI03-2	Diagnosis Code	Required	Valid External Causes of Injury Codes	Gateway Health Plan only accepts valid ICD-9 Diagnosis Codes and will status back any claims with codes that are not valid
232	2300	HI01-1	Diagnosis Type Code	Required	"BF" for Additional Diagnosis Codes	Providers should continue to use HI02 to HI12 to continue to report additional diagnosis codes and use qualifier "BF"
232	2300	HI01-2	Diagnosis Code	Required	Valid Additional Diagnosis Codes	Gateway Health Plan only accepts valid ICD-9 Diagnosis Codes and will status back any claims with codes that are not valid
230	2300	HI01-1	DRG Type Code	Required	"DR" for Other Diagnosis Related Group Codes
230	2300	HI01-2	DRG Code	Required	Valid DRG Codes	Gateway Health Plan only accepts valid DRG Codes and will status back any claims with codes that are not valid
447	2400	SV201	Service Line Revenue Code	Required	Valid Revenue Codes	Gateway Health Plan only accepts valid Revenue Codes and will status back any claims with codes that are not valid
447	2400	SV202-2	Procedure Code	Required	Valid HCPCs & CPT Procedure Codes	Gateway Health Plan only accepts valid HCPCs & CPT Procedure Codes and will status back any claims with codes that are not valid
447	2400	SV202-3	Procedure Code Modifiers	Situational	Valid Modifiers	Gateway Health Plan only accepts valid Modifier Codes and will status back any claims with modifiers that are not valid. Provider should continue to use elements SV202-4 to SV202-6 to report additional modifiers. Providers billing physician services on
447	2400	SV203	Line Item Charge Amount	Required	Cost of item or service in USA dollars
447	2400	SV204	Unit or Basis of Measurement Code	Required	Use "UN" for units or "DA" for days
447	2400	SV205	Quantity	Required	Number of services, or days, or units provided
456	2400	DTP01	Date/Time Qualifier	Required	"472" for Date/Time Qualifier
456	2400	DTP02	Date/Time Period Format Qualifier	Required	"D8" : One date in CCYYMMDD format "RD8" : Span of dates using CCYYMMDD-CCYYMMDD format	Gateway Health Plan accepts both formats for the dates and recommends that the dates be populated at the service line level, rather than at the claim level
456	2400	DTP03	Date Time Period	Required	Date or Date Range
	Various	PRV03	Provider Taxonomy Code	NOT Required		Gateway Health Plan does not require the taxonomy code

Medicaid

Gateway Health Care Claim Institutional ASCX12N 837 (004010X096 May 2000 & 004010X096 A1 Oct 2002)