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Formal vs. Informal Help Informal Formal

Submitter

Cheryl Cochrane

Description

SC Medicaid is returning two NM1 segments within one LS/LE loop. Our interpretation is that only one NM1 segment is allowed per the 5010 companion guide which states the segment repeat is 1. Therefore, we're only reading the first NM1. Our trading partner is saying more than one NM1 is allowed as long as there is a LS/LE loop but we feel that each NM1 segment should be contained in a separate LS/LE loop. Are we correct?
This is what SC Medicaid is returning:
NM1*1P*2*CAROLINA FOREST FAMILY MED*****SV*GP3722~
N3*4022 POSTAL WAY~
N4*MYRTLE BEACH*SC*29579~
PER*IC**TE*8432369925~
LE*2120~
EB*D**44******VS*50~
EB*D**33******VS*6~
EB*D**A4******VS*12~
EB*J**A9****0**P6*420~
SE*34*0001~

Response

No, your interpretation is not correct. It appears that you are confusing the distinction between loop and segment repeats. The 005010X279A1 Technical Report Type 3 specifies that the LS Loop Header and LE Loop Trailer segments occur only once within each 2110C loop. The LS/LE loop header and trailer serve as the boundary encapsulating all the repeats of the 2120C loops within one 2110C loop.

The 2120C Subscriber Benefit Related Entity Name LOOP may repeat up to 23 times between the LS and LE segments. The 2120C loop is comprised of the NM1, N3, N4, PER, and PRV segments. The NM1 Subscriber Benefit Related Entity Name SEGMENT may occur only once within each REPEAT of the 2120C loop. But, this means there can be up to a total of 23 occurrences of the NM1 within the LS/LE boundary.

In your specific example, the two 2120C loops are identifying the primary care (EB*L) Gateway Provider (NM1*GW) and Provider (NM*1P)

Recommendation

The table in section 2.5.1 of the TR3 is very helpful when reviewing loop and segment nesting and repeat limits.
Submission 5/30/2013
Status Date 7/9/2013
Status F - Final
Primary References
Document 005010X279
Section2.6