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Back  RFI # 2148: Primary Care Provider 2310A NM

Formal vs. Informal Help Informal Formal

Submitter

Betty Westbrook

Description

Can you provide clarification on the use of the "P3" (Primary Care Provider) in Loop 2310A, segment NM1? The guide states that "When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code "P3 - Primary Care Provider" in the second iteration of the loop"

It also says that the Loop repeat is 2 and the segment repeat is 1. Does this mean that there can only be 2 iterations of this loop and 1 iteration of this segment per loop?

Example 1:
2310A NM1*DN*1*DOE*JANE***MD*XX*1234567890~
2310A NM1*P3*1*DOE*JOHN~
OR
Does this mean that there can be 1 iteration of this loop and then repeated 2 times (for a total of 3 iterations)
Example 2:
2310A NM1*DN*1*DOE*JANE***MD*XX*1234567890~
2310A NM1*DN*1*DOE*MARY***MD*XX*2345678901~
2310A NM1*P3*1*DOE*JOHN~

A Payer is stating that in order to use the NM1*P3, there needs to be 2 NM1*DN segments (example 2) in order for this claim to pass the front end edits. Is the requirement of the payer permissible?

Response

The requirement to submit two referring providers (2310A loop with a DN qualifier in the NM102) as a condition for submitting a primary care provider (2310A loop with a P3 qualifier in the NM102) is not compliant with the TR3. To be compliant with the guide, a single referring provider must be submitted prior to submitting the primary care provider information. The intent of the quoted instruction is for situations when someone other than the primary care provider made the referral for example when a specialist refers the patient to another specialist. In which case the first iteration of the NM1 segment would contain the specialist and the second iteration would identify the patient's PCP.

The loop repeat captures the maximum number of times a loop may appear within the next higher loop. In the case of the 2310A the loop repeat is two so it may be repeated a maximum of two times per 2300 loop. The segment repeat captures the number of times a segment may appear within the loop. The segment repeat for the 2310A NM1 is one, so each 2310A may contain only one NM1 segment.
Submission 5/25/2016
Status Date 7/5/2016
Status F - Final
Primary References
Document 005010X222
Section2
Set ID837
Table2
Loop2310A
Segment IDNM1
Element Position01
Industry NameEntity Identifier Code
Code ValueP3