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Back  RFI # 131: Correct Patient/Insured Name

Formal vs. Informal Help Informal Formal

Submitter

William Costello

Description

Our MCO is changing our member ID #'s from SSN-based #'s to sequential #'s. On 835, on NM1 with 74 entity identifier code, does insured refer to patient or to contract-holder? Original claim submitted with old member #, but paid under new member number. Should NM1*74 segment contain old member # as submitted on claim, or the new member # in NM109? Which member# should be placed in NM1*QC and NM1*IL segments?

Submitter Assigned Keywords

835 NM1*74 Corrected Patien/Insured Name

Response

This issue is explicitly answered in guide X091 in section 3.1 on page 108. The insured is the contract holder. This NM1 segment contains the corrected insured always. Sometimes, the insured is the patient. The "74" segment must contain the new ID number. The "QC" and "IL" segments must contain the information submitted on the claim.
Submission 11/10/2004
Status Date 11/10/2004
Status F - Final
Primary References
Document 004010X091
SectionDetail
Page110
Set ID835
Table2
Loop2100
Segment Position030
Segment IDNM1
Element Position09
Industry NameIdentification Code