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Back  RFI # 1885: 5010 835 Claim Status 4

Formal vs. Informal Help Informal Formal

Submitter

Chris Weber

Description

Hello,

I would like to verify the understanding of the 5010 835 rule where Payers should only be using the Claim Status of 4 in a 5010 payment to report when the member did not have coverage.
Besides the PR177 CAGC/CARC code, are there any other codes that can be used with a claim status of 4 within the 5010 format?


Thanks,
Chris Weber

Submitter Assigned Keywords

5010 835 Claim Status 4

Response

As specified in the 005010X221A1 Technical Report Type 3 (TR3) and explained in RFI 1423, CLP02 code 4 can only be used if the Patient/Subscriber is not recognized by the health plan, and the claim was not forwarded to another payer.

Your question and CAGC/CARC PR*177 imply that the member is recognized by the health plan, but has not met eligibility requirements. Code 4 is not appropriate for that situation. Assuming the health plan was billed as primary, CLP02 code 1 (Processed as primary) is appropriate. CAGC/CARC PR*31 (Patient cannot be identified as our insured.) is an example of a CAGC/CARC for which CLP02 code 4 is appropriate.
Submission 12/5/2013
Status Date 2/7/2014
Status F - Final
Primary References
Document 005010X221
Section1.1
Page124
Set ID221