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Back  RFI # 1369: CLM07 for Medicare Claim

Formal vs. Informal Help Informal Formal

Submitter

Deanna Stohl

Description

With the changes in the 5010 version of the 837, the rules regarding the population of the CLM07-Provider Accept Assignment Code have caused some concern regarding the submission/receipt of Medicare claims.It is our understanding that the participation status of the providers servicing our members is mutually exclusive to the participation and/or Assignment arrangements of these providers with Medicare/Medicare Advantage. It is necessary for our plan to understand if a Medicare claim submitted to us contains a value that denotes whether the provider participates with Medicare and/or Accepted Assignment. This information is used to determine if we pay the provider directly or bill the subscriber. In addition, it helps us determine the fee schedule that must be applied when making a payment.Please provide guidance on how to expect the 5010 CLM07 to be submitted when provider is par with destination payer but not with Medicare and vice versa.

Submitter Assigned Keywords

CLM07 provider par w/ destination payer but not w/ Medicare & vice versa

Response

The intent of the code value ‘A’ (Assigned) in CLM07 is to report when the provider accepts assignment and/or has a participation agreement with the destination payer.

OR

When the provider does not accept assignment nor have a participation agreement
but is advising the destination payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans.

Recommendation

Recommendation: Submit questions to CMS Medicare at 5010ffsinfo@cms.hhs.gov regarding usage of data element CLM07 in the Medicare crossover process.
Submission 7/29/2011
Status Date 3/2/2012
Status F - Final
Primary References
Document 005010X222
Section2.4
Page160
Loop2300
Segment IDCLM
Element Position07