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Back  RFI # 263: NM1*IL on Medicare/Medicaid

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Submitter

Janice Cunningham

Description

Segment: NM1
Loop: 2100

Notes:
2. In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment should not be used.

A payer is sending files with MC reported in CLP06 indicating the claim is a Medicaid claim.
The payer is sending NM1*IL segments for these claims.

Per my understanding of the 835 4010A1 IG "should not" is to be understood as "must not".

Please clarify whether or not NM1*IL can be reported in claims with MC, MA or MB reported in CLP06.

Response

The insured name NM1 segment must not be used when the patient is the subscriber. This segment is only used when the insured is different than the patient. In the case of the Medicare and Medicaid benefit programs, the subscriber is the patient. Therefore this segment would not be used by CMS nor any state Medicaid program.
Submission 6/8/2005
Status Date 9/16/2005
Status F - Final
Primary References
Document 004010X091A1
SectionNM1*IL
Page105
Set IDNM1*IL