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Back  RFI # 759: 835 - Insured Name

Formal vs. Informal Help Informal Formal

Submitter

Karen Shutt

Description

We would like clarification on the use of the NM1 segments for Patient, Insured and Corrected Patient/Insured with respect to submitted data vs. adjudicated (corrected) data.
TR3 Note 2 on the Insured NM1 segment seems to be in conflict with the Situational rule for the Insured segment especially as it relates to submitted data. The insured segment is only required when the subscriber and patient are different so how can TR3 Note # 2 apply?

If an 837 was submitted with the patient as the subscriber, but in processing it was determined the patient is actually a dependent, what should be reported in each of the 3 segments or would only the Pt and Corrected NM1 be reported? We assume the Insured segment would not be reported since it is submitted data and the patient and insured were submitted as the same entity. If the later statement is true, how will the provider know if the Corrected NM1 pertains to the Corrected Pt or Corrected Insured data?

Response

In the 5010 835 TR3, the Situational Rule on the Insured segment takes precedence over the TR3 Note 2 which should be ignored.

Recommendation

The workgroup offers this response on how to value the NM1 segments in the 835

1. The Patient NM1 segment is required.

2. If subscriber submitted on the claim was different than the patient, then the Insured NM1 segment is required.

3. If the subscriber/insured information submitted on the claim does not match how the payer expects to see the claim, then the Corrected Patient/Insured NM1 segment is required to report what the claim information should have been.
Submission 4/8/2009
Status Date 12/11/2009
Status F - Final
Primary References
Document 005010X221
Section2.4
Page140
Set ID835
Table2
Loop2100