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Back  RFI # 816: 271, NM110 Entiry Relationship

Formal vs. Informal Help Informal Formal

Submitter

karthik Subramanian

Description

Within the 271 TR3 of the 2120C loop the NM1 segment has the following situational rule:


Required when needed to indicate the Benefit Related Entity’s relationship to the patient when EB01 = “R”, the coverage is based on the Benefit Related Entity and the
relationship is known.

Question: Does this statement imply that the Benefit Related Entity's relationship (NM110) is required when EB01 = R.

Thanks in advance.

Response

This issue is explicitly addressed in guide 005010X279. The situational rule on 2120C NM110 reads "Required when needed to indicate the Benefit Related Entity’s relationship to the patient when EB01 = “R”, the coverage is based on the Benefit Related Entity and the relationship is known. If not required by this implementation guide, may be provided at sender’s discretion, but cannot be required by the receiver." EB01="R" is not the only part of that rule. In addition to EB01 = "R", other requirements exist, including that the Information Source know the relationship.

Also, the Situational Rule on that NM1 segment states that the entity identified could be "an individual, an organization, another payer, or another information source". All of those entities do not have a relationship to the patient that can be identified by the codes in NM110.

As a result, NM110 is not always required when EB01 = "R".
Submission 7/23/2009
Status Date 7/28/2009
Status F - Final
Primary References
Document 005010X279
Section706
Page334
Set ID271