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Back  RFI # 1288: 2110 DTM for predeterminations

Formal vs. Informal Help Informal Formal

Submitter

Karen Shutt

Description

Our dental business has claims that contain both paid service lines and pre-d service lines on the same claim. We set the claim status (CLP02) to 1 (processed as primary), due to the paid service lines. We are unable to report the 19000101 date for the pre-d Service line due to the TR3 Note (#6) that only allows the pre-d date to be reported when the CLP02 value is 25. To avoid translator/validation errors on the pre-d service line, we are reporting claim level dates based on the paid line(s) date and then NOT reporting a service level date on the pre-d line since a claim level date was already reported. Is this the most appropriate workaround for this situation? Recommend the next guide be enhanced to address this situation and/or remove the requirement for the 19000101 date and it being tied to CLP02=25.

Response

If the claim is coming in electronically as a dental 837, please note that the 837 Dental Claim does not permit rendered services to be mixed with services for predetermination and it should be rejected.

If this is a result of a paper claim, this would be an ideal candidate for claim splitting.

Please refer to section 1.10.2.11 of the guide, Claim Splitting. The paper claim would need to be split on the 835 between rendered services in one CLP and the predetermination in another CLP. Neither the date nor the CLP02 is an issue in the predetermination.
Submission 3/31/2011
Status Date 6/1/2011
Status F - Final
Primary References
Document 005010X221
Section2.4
Page194
Set ID835
Table2
Loop2110
Segment IDDTM