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Back  RFI # 963: Corrected Priority Payer Name

Formal vs. Informal Help Informal Formal

Submitter

Heath Vaughn

Description

Per the 5010 835 TR3:

The 2100 NM1 Corrected Priority Payer Name segment is situational and required when the payer believes that another payer has priority for making payment.

The payer meets the situational rule, but:

Scenario 1:
The payer does not have the corrected payer identification number (NM109) in their system. The NM109 data element is required. Can the payer send the segment with missing “required” data?

Scenario 2:
The payer has the payer identification number on file, but there is no way to verify it to determine if it is correct. Should the payer send the segment, even though the data may be incorrect?

Submitter Assigned Keywords

Corrected Priority Payer Name

Response

In respect to Scenario 2: If the data is known and available in the health plan’s system then it should be sent with the assumption it is valid.

In respect to Scenario 1: The NM1 Corrected Priority Payer Name Segment is required and not sending both the Payer Name and ID is non-compliant. The available Payer ID qualifiers are: AD - BCBSA Plan Code, FI – FTIN, NI – NAIC ID, PI – Payor ID, PP – Pharmacy Processor Number, XV – Healthcare Financing Administrative National PlanID .

Recommendation

The PI (Payer ID) qualifier can be used to represent the current Health Plan’s proprietary ID for the corrected priority payer.
Submission 2/15/2010
Status Date 5/21/2010
Status F - Final
Primary References
Document 005010X221
Section2.4
Page153
Set ID835