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Back  RFI # 2281: Subscriber/Patient address

Formal vs. Informal Help Informal Formal

Submitter

Doug Nelson

Description

Regarding the 837 professional 005010X222A1 TR3.

Could we receive a claim with the N3, N4 and DMG segments in both the subscriber name loop (2010BA) and the patient name loop (2010CA)?

We have never received a claim with those three segments in both loops. We receive lots of claims where the NM1 IL segment is present in loop 2010BA and the NM1 QC segment is present in loop 2010CA, but the address is always in loop 2010CA when NM1 QC segment is used. On the CMS-1500 claim form, there is a box (5) for the patient address and a box (7) for the insured’s address, so it seems like we could receive a claim with a subscriber address and a patient address.

The documentation (page 124) for the N3 Subscriber Address segment contains a Situational Note that says, “Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.”. Does this note prohibit using the N3 segment in loop 2010BA if the N3 segment is used in loop 2010CA?

Response

This issue is explicitly addressed in the 005010X222A1 TR3. The Loop 2010BA segments, N3 - Subscriber Address and DMG – Subscriber Demographic Information are “Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.” Therefore, if the patient is the subscriber or considered to be the subscriber, the patient address and demographic information must be sent in the 2010BA Loop. If the patient is not the subscriber or considered to be the subscriber, the patient address and demographic information must be sent in the 2010CA Loop.

The Situational Usage Rule of the Loop 2000C HL - PATIENT HIERARCHICAL LEVEL states, “Required when the patient is a dependent of the subscriber identified in Loop ID-2000B and cannot be uniquely identified to the payer using the subscriber's identifier in the Subscriber Level. If not required by this implementation guide, do not send.” Therefore, if the patient is the subscriber or considered to be the subscriber, the patient Loop and corresponding Loop 2010CA segments must not be sent.

It is not compliant with the TR3 to send an address for both the Subscriber in Loop 2010BA and the patient in Loop 2010CA.
Submission 4/4/2018
Status Date 5/11/2018
Status F - Final
Primary References
Document 005010X222A1
Section2.3.1
Page124
Set ID837
Table2
Loop2010BA
Segment Position0250
Segment IDN3
Element Position1
Industry NameSubscriber Address