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Back  RFI # 1423: 835 CLP02: Claim Status Code 4

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Michele Pace


Can you please elaborate on the definition of "Denied" clp02 status 4. Is this ONLY for claims where the patient/subscriber could not be identified or is this just an EXAMPLE of when to use it.

We had one payer change their definition to ONLY be where they could not identify the patient/submitter and NO LONGER send this status for those claims where no payment was made by the payer.

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This issue is explicitly addressed in guide 005010X221. The note on CLP02 code 4 reads "Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer."

Code 4 can only be used in that situation. If the patient/subscriber is found in the payer's system, then the payer is able to process the claim, and codes 1, 2 or 3 apply, even when the processing result is no payment. Those codes state "processed", not "paid". The payer that changed their definition has changed it to be consistent with the implementation guide. CARC and RARC codes are used to derive the rationale if the claim or service was denied.
Submission 9/30/2011
Status Date 11/16/2011
Status F - Final
Primary References
Document 005010X221
Set ID835
Segment PositionCLP02
Segment IDCLP
Element Position02