I was wondering if you could tell me if the below scenario with the two NM1 segments was violating the spec based on Spec Section 2.4 on Segment Definition NM1 where qualifier equals QC and IL. Page 137 and 140.
We have a payer that is sending back both the patient NM1*QC and the subscriber NM1*IL segments when the patient information is the same, indicating that they are the same entity. The payer is doing this for all of their claim payments. According to the spec Situational Rule: Required when the insured or subscriber is different from the patient. If not required by this implementation guide, do not send.
Patient: NM1*QC*1*PAT*A~
Subscriber: NM1*IL*1*PAT*A****MI*123456789~
The 5010 TR3 guide’s situational rule is clear in stating; “Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send.” If the patient is the same as the insured, the insured segment must not be sent.