Name and Address Segments (NM1, N3, N4) in X12 EDI

Here is a typical snippet of EDI representing a billing provider’s name and address.

Note that NM1 segment includes the provider’s NPI number besides the usual name and address fields. It is a common theme with EDI – identifiers are oftentimes submitted alongside names. In the case of healthcare claim transactions, an NPI is actually mandated for all billing providers.

Here is another examples, this time, of an EDI receiver with a different ID type.

How do we know that these segments belong to an EDI receiver? Just mouse over 40, you will see that it is an element called ““Entity Identifier Code” and 40 means “Receiver”. Similarly, 85 in the previous example stands for “Billing Provider”. “Code” fields or qualifiers fields are frequently used in EDI to provide context or to make a segment more specific.

EDI and healthcare data in general use many codes, including procedure and diagnosis codes. With our EDI/Claim Viewer a code’s description is always available in the tooltip.

Subscriber’s or Patient’s Name and Demographics

A patient’s name and address look similar to a provider’s but this is a rare instance when an ID is not required.

In addition to names and addresses, subscriber/patient information could also include a DMG segments containing a date of birth and, optionally, a date of death, as well as gender.

Providers’ Names and Addresses

A healthcare claim very often contains information about multiple providers. A billing provider is always required. Optionally, a claim could also specify “rendering”, “referring” and various other providers who were involved in providing care to a patient:

Provider’s information may or may not include an address.

EDI 837 standard requires providing addresses for “Service Facility” (a facility, that is, a place where services were performed, is considered a provider type), but not for rendering/performing providers.

A provider’s address can almost always be found in the NPPES registry which contains information on all providers in the US, including their addresses.

An additional piece of provider-related data that can supplied on a claim is provider’s specialty, expressed using their taxonomy code. Providers can have multiple specialties so specifying the exact code used as part of the service may be sometimes mandated by insurance companies. The taxonomy code is provided using the PRV segment.