A state Medicaid payer is requesting the name of an organization or the word "UNKNOWN" in NM103 when the referral came from a group or organization. This is an excerpt from their companion guide:
NM103 - Name Last or Organization - When Access PCP is a group or office, please provide name of organization as the provider last name or UNKNOWN.
The group NPI should be reported in NM109.
The only qualifier allowed for 2310F NM1 segment in NM102 is "1" - Person, so we stated that an organization and its associated NPI shouldn't be sent, only an individual should be identified as the referral. Medicaid is using the argument that the element name for NM103 states "last name or organization name". which allows them the ability to report an organization in this loop. We have argued that the qualifier in NM102 quantifies what is allowed in NM103 to no avail. X12 ruled on the naming convention of NM103 in RFI 1536, but because that RFI references Loop 2310A, they don't feel this is applicable to Loop 2310F.
The 2310F referring provider is the person not the organization who sends the patient to another provider for services. The provider’s individual NPI must be reported in the NM109 not the organization’s NPI.
In the 2310F NM103 the phrase “Name Last or Organizational Name” refers to data element 1035 in the X12 standard. The TR3 defines this specific NM103 (DE 1035) to be the “Referring Provider Last Name”. Also the NM102 only allows for a value of 1 for person.