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Formal vs. Informal Help Informal Formal

Submitter

Kim Walker

Description

A payer is returning ERA files to providers without a name in Loop 2100-NM1 Patient Name segment. Although the loop is required, NM103, NM104 and NM105 are marked as Situational, but noted that they are required when the patient has a last, first name.The payer is instead returning the patient's name in Loop 2100-NM1 Corrected Patient/Insured Name only.

Ex: NM1*QC*1~NM1*74*1*Last*First*D***C*policy no~

Can I have an interpretation of the usage of this Loop and Segment and specifically data elements NM103, NM104, NM105, please?

Submitter Assigned Keywords

ERA Medi-Cal NM1*QC

Response

The 5010 TR3 explicitly states that the Patient Name segment is required and MUST be sent. Elements NM101 , NM102 are required and NM103 is required for ALL claims that are not Retail Pharmacy. Elements NM104 and NM105 are situational, but the payer is required to send this information if it was received on the claim or if it is known.

The use of the Corrected Patient/Insured is for situations where the claim information is different than the information that the payer knows or has from their system or files. In those cases, the payer would supply the Corrected Patient/Insured segment (with the information from their files) along with the Patient Name segment (with the information from the claim). There is no situation in which the Patient Segment is not sent.
Submission 10/5/2012
Status Date 11/27/2012
Status F - Final
Primary References
Document 005010X221
Section2.4
Page137
Loop2100
Segment Position0300
Segment IDNM1
Element Position03
Industry NamePatient Name