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Back  RFI # 1239: 5010 835 Cov Expiration Date

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Submitter

Tony Voris

Description

In the reviewing our implementation for the 5010 835 DTM Coverage Expiration segment, we have a scenario which may cause compliancy issues.

We process claims for subscribers in which membership is contained on a partner system (i.e. FEP). During claim adjudication, the partner system is accessed for eligibility. For these claims, we do know if a claim was rejected due to a Coverage Expiration, however, the actual coverage expiration date may not be available.

We would report the CARC code of 27 on the claim, but would not be able to report the corresponding Coverage Expiration DTM*036 segment as that date is not available.

For these claim scenarios in which the Coverage Expiration Date is not available, we had intended to map a date to the Coverage Expiration Date that is prior to the earliest date of service on the claim.

What is the proper way to report these claims on the 835 to ensure compliance?

Submitter Assigned Keywords

5010 835 DTM Coverage Expiration Date

Response

The guide explicitly states in the situational rule when the coverage expiration date is to be used. "Required when payment is denied because of the expiration of coverage." So in the case where the claim was denied because the coverage expired that date has to be present.
Submission 2/15/2011
Status Date 4/21/2011
Status F - Final
Primary References
Document 005010X221
Section2.4
Page175
Set ID835
Table2
Loop2100
Segment IDDTM
Industry NameCoverage Expiration