Change Request Detail
No.
1015
Date
10/26/2004
Submitter
Type of Request
Payment of a Health Care Claim
Status
DSMO Process Completed
Business Reason
The way the imp guide is written - there's no way for the payer to say "no middle initial" and not violate an X12 rule.  Bottomline to me as a provider - every time a payer does this - my 835 FAILS in validation... and has to be manually handled.

The scenario is John Z Doe is the patients Name - but the payer system has him listed as John Doe - and thus his  Benefits are under his name withoug a middle initial.
    
Provider submits the claim WITH the "Z" in the middle name, and the payer wants to report back that there is no middle initial.
    
Here's the problem in an example:  Patient name John Z Doe - payer has John Doe:
    
NM1|74|1~ - invalid since there's not any NM03, 04, or 05 data
NM1|74|1||| ~ - invalid - leading spaces not allowed, excess delimiters
NM1|74|1|Doe|John~ - violates the guide as Doe and John were correct - however -  this would tell me the "Z" is what is NOT on the payer system - if the IG were to be worded to allow this  (i.e. report the full name as the payer has it on their system).
    
Suggestion
The IG needs to be clear about usage:

1.  is it reporting differences in names/spelling
2.  is it intended to also or only report if the payer thinks the subscriber paid is a DIFFERENT person than the one billed.

Either way - suggest that the guide then define the appropriate way to report - and to eliminate any ambiguity, suggest that the full NM1 segment - at least when it's a name - that the Fist, last, AND middle initial be reported as the payer has it - allowing the provider to compare and identify if the first, last or middle is what's different - don't leave it to interpretation.
DSMO Category
B
Recommendation
Approve. The DSMO agree that further clarification is needed and will be incorporated into the next guide. The DSMO recommend that X12N take into account the submitter's suggestion: "suggest that the guide then define the appropriate way to report - and to eliminate any ambiguity, suggest that the full NM1 segment - at least when it's a name - that the first, last, AND middle initial be reported as the payer has it - allowing the provider to compare and identify if the first, last or middle is what's different - don't leave it to interpretation." to determine the most appropriate clarification.
Appeal Recommendation