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Back  RFI # 456: NM1*IL on Medicare/Medicaid

Formal vs. Informal Help Informal Formal


Janice Cunningham


I have of payers who continue reporting NM1*IL when CLP06 is MA, MB or MC. Please review the following and confirm is this is acceptable or not.

"I'm reading the NM1 Segment to say if the Payer is Medicare or Medicaid then the patient is always the insured. Because, as I’m sure we are all aware, this is true only when speaking of these government programs. I don’t believe the Implementation guide would be speaking of Health Plans just offering a Medicare or Medicaid Product type. CLP06 is just a means for a Payer to denote what type of Product the member has; POS, HMO, Medicare, etc. We are not a Medicare Payer but only offering a Medicare product. For BCN, to say that when we offer a Medicare Product that the patient is always the insured may not even be true. We have groups that can offer a BCN Advantage product and the patient on the claim may not be the insured (but a dependent on the contract). "
I have additional comments from the payer.

Submitter Assigned Keywords

NM1*IL with CLP06 MA, MB MC


According to the request, the payer is not Medicare or Medicaid, but has a Medicare HMO type of product. In that case, usage of MA, MB or MC in CLP06 is not appropriate. If the product is an HMO product, CLP06 should be 16 (if it is a Medicare Risk HMO) or HM. If the product is not an HMO, then the appropriate Claim Filing Indicator should be used, but not MA, MB or MC. In that case, there are situations where the insured is not the patient and usage of the Insured NM1 is required. Outside of Medicare (carrier or intermediary) or Medicaid, the 4010 guide does not explicitly prohibit usage of the Insured NM1 when the patient is the insured, although that was the intent.


Since the latest implementation guide explicitly prohibits usage of the Insured Name NM1 segment when the insured is the patient, we recommend all payers refrain from sending an Insured Name NM1 segment when the insured is the patient, even under 4010.
Submission 9/27/2006
Status Date 11/22/2006
Status F - Final
Primary References
Document 004010X091A1
Section2100 NM1
Segment IDNM1
Element Position01