RFI Browser

Back  RFI # 179: Medicare Crossover Claims

Formal vs. Informal Help Informal Formal

Submitter

Paulette Turner-Coleman

Description

We receive Medicare crossover claims from the Medicare carrier and intermediary with the patient as the insured (837/ 2010AB Loop - Subscriber Name). The patient is not always our insured. On the 835 we have been sending an NM1*IL (2100 Loop) and a NM1*74 is the corrected information.

My question is, do we have to pass the NM1*IL with the information that was submitted from Medicare or can we just plug the correct insured information in the NM1*IL and not send the nm1*74?

Response

This issue is addressed in guide 004010X091 on pages 105 and 108. The Insured NM1 segment is used when the payer received insured information on the claim that was different than the patient. Since the Medicare secondary claim did not identify an insured separate from the patient, the Insured Name segment does not apply and is not used. The Corrected Patient/Insured Name segment applies and must be used to identify the insured as different than the patient. So, your 835 for these claims should be sending an NM1*QC and an NM1*74, but not an NM1*IL.
Submission 1/19/2005
Status Date 3/7/2005
Status F - Final
Primary References
Document 004010x091a1
SectionSegments
Page106
Set IDNM1
Table1
Loop2100
Segment Position030
Segment IDNM1
Element Position01