Patient Relationship To Member/Insured
What’s in the box?
This box indicates the patient’s relationship to the Insured (the Policyholder). For example, if the patient is the Policyholder (their Policy Member ID is reported in box 1a), then check ‘Self’.
Where does this info live in Jane?
This can be found by heading to the Patient Profile> Billing> Insurance Policies and clicking View on an existing Policy or creating a New Insurance Policy. Under the Insured’s Info heading, you can use the drop-down menu to set the Patient Relationship to Insured.
Note: by default, each new Policy is set to Self, which means the patient is the Policyholder. If an option other than Self is chosen, then a prompt to fill out some information for the Insured will appear.
Is this required?
The patient’s relationship to the Insured is required on the CMS1500.
The patient’s relationship to the Insured is required when billing via EDI file.
What about the EDI file?
Although the patient’s relationship to the insured is always required, where this information is sent in the EDI is situational.
Option 1: Patient is the Subscriber
If the patient is also the subscriber (the patient is the one who holds the insurance policy), then Loop 2000C - Patient is not sent in the EDI. In this case, the patient relationship to the insured is only indicated in Loop 2000B - Subscriber.
- The patient’s relationship to the insured is sent in HL - Loop 2000B - Subscriber, Segment HL04
- 0 will be sent in this scenario (‘0’ means the patient is the subscriber)
Option 2: Patient is not the Subscriber
If the patient is not the subscriber (i.e. their spouse is the Policyholder and they are covered under that Policy), then the patient relationship to the Insured is sent in Loop 2000B - Subscriber AND it is also sent in Loop 2000C - Patient.
- The patient’s relationship to the insured is sent in HL - Loop 2000B - Subscriber, Segment HL04
- 1 will be sent in this scenario (‘1’ means the patient is not the subscriber)
- The patient’s relationship to the Insurer is sent in HL - Loop 2000C - Patient, Segment PAT01
The following possible options for relationships: