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Submitter

Dora Lambert

Description

In the 5010 TR3, the definition of the CLP02, claim status code 4, has changed to "usage of this code would apply if the patient/subscriber is not recognized, and the claim was not forwarded to another payer.

Must a payer use the claim status code of 4 if the patient/subscriber is not recognized in their system, and the claim was not forwarded to another payer, or do they have the option of using status codes 1, 2, or 3 and still be compliant? CARC A1 and RARC N382 can be used with 1, 2 or 3. We believe this combination of codes provides the full claim status; however, if there is concern that the RARC may be removed by a 3rd party, we can request a CARC similar to the N382 RARC.

While we realize some payers would rather use a value of 4 instead of claiming to be the primary, secondary or tertiary payer, the Medicaid payers may not have this same concern since they are payers of last resort.

Submitter Assigned Keywords

CLP02, claim status denied, determining full claim status.

Response

The note on Claim Status Code "4" states "Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer." The descriptions of codes "1". "2" and "3" includes "processed as...".

If the patient can not be found in the payer's system, then the claim can not be processed. The payer can't determine whether to process as primary, secondary or tertiary. While a Medicaid may not be concerned about this, they still can't process the claim since there is no patient identifiable in their system.

Therefore, for standardization, when the patient is not recognized and the claim is not forwarded, only Claim Status Code "4" can be used.
Submission 6/21/2010
Status Date 7/2/2010
Status F - Final
Primary References
Document 005010X221
Section2.4
Page124
Set ID835
Table2
Loop2100
Segment Position0100
Segment IDCLP
Element Position02
Industry NameClaim Status Code
External Code List835W1_2100_CLP02_Claim Status
Code Value4