Section title: Requests for Interpretation
Do not send segment 2100 NM1*QC (Insured) when 2100*NMIL (Patient) has the same name

We currently have a provider stating the logic for 835s is incorrect due to our 835 files being sent with both 2100 NM1*IL and NM1*QC when patient name is the same as the insured name.

We are questioning this logic as there is no way to verify insured DOB for the 835 file- so we are unable to determine whether the patient and insured are the same in cases where the Insured and Patient really do have the same name but are separate people. This may happen in cases where dependents are named after subscriber and do not have a suffix to identify them as different people.


John Smith born 01/19/1980 has a son born 05/24/2005 and names his son John Smith- without a middle name or suffix to identify the insured vs subscriber.

RFI Response

In 5010X221A1 the 2100 NM1*QC and the NM1*IL are reported when the submitted subscriber is different from the patient. There is not a way within the 835 data to validate that the entities are different if the names are the same as is described in this RFI scenario. Verification of this would fall on the payer and provider. The intention of the situational rule is that the payer will only report the NM1*IL when the subscriber is different than the patient.

Future published versions of the 835 will help support clarification however they are not mandated for use at this time.