Transmission Examples: NPI/Provider Contract ID validation: NPI Providers Loop Segment Name Code Length Notes/Comments 2100B NM108 Identification Code XX The National Qualifier Provider ID must be submitted 2100B NM109 Identification Code 10 The National (Information Provider ID must Receiver be submitted Identification Number OR Atypical Providers Loop Segment Name Code Length Notes/Comments 2100B REF01 Reference 1D For Atypical Identification Provider use only Qualifier 2100B REF02 Reference 12 12-digit Payment Identification Contract for Atypical Provider use only Minimum client data needed for search: Utah Medicaid Client Identification Number and Full Name Loop Segment Name Code Length Notes/Comments NM103 Subscriber Last Utah Medicaid Name Recipient’s Last Name 2100C NM104 Subscriber First Utah Medicaid Name Recipient’s First Name 2100C NM108 Identification Code MI Qualifier 2100C Identification Code 10 Utah Medicaid (Subscriber) Recipient’s 10-digit Medicaid ID Number
Transmission Examples: NPI/Provider Contract ID validation: NPI Providers Loop Segment Name Code Length Notes/Comments 2100B NM108 Identification Code Qualifier XX The National Provider ID must be submitted 2100B NM109 Identification Code (Information Receiver Identification Number 10 The National Provider ID must be submitted OR Atypical Providers Loop Segment Name Code Length Notes/Comments 2100B REF01 Reference Identification Qualifier 1D For Atypical Provider use only 2100B REF02 Reference Identification 12 12-digit Payment Contract for Atypical Provider use only Minimum client data needed for search: Utah Medicaid Client Identification Number and Full Name Loop Segment Name Code Length Notes/Comments NM103 Subscriber Last Name Utah Medicaid Recipient’s Last Name 2100C NM104 Subscriber First Name Utah Medicaid Recipient’s First Name 2100C NM108 Identification Code Qualifier MI 2100C Identification Code (Subscriber) 10 Utah Medicaid Recipient’s 10-digit Medicaid ID Number