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Back  RFI # 1945: Replacement Claim CLP01

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Submitter

Jeanne Kirkpatrick

Description

A hospital submitted an ORIGINAL claim with CLM01 of H767800. Then submitted a REPLACEMENT claim (CLM05-3=7) with H767802 in CLM01. A 2nd REPLACEMENT claim was sent with H767804 in CLM01. However, the 835s CLP01’s have the ORIGINAL claim CLM01. The hospital believes the CLP01 for each 835 should be the same as the submitted CLM01 from the respective 837.
The 835 CLP01 states “Use this number for the patient control number assigned by the provider...The value in CLP01 must be identical to any value received as a Claim Submitter’s Identifier on the ORIGINAL claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider’s database.” Is each REPLACEMENT considered a new ORIGINAL?
RFI 1799 recommends “For the business stated, there is only one claim - the original that is now being voided. It is recommend that the CLM01 of a void claim equal the CLM01 of the original.” Is this recommendation the same for a replacement claim?

Submitter Assigned Keywords

835 CLP01 replacement claim CLM01 claim submitter's identifier

Response

This issue is explicitly addressed in guide 005010X221A1. As you state in your request for interpretation the CLP01 note reads in part “The value in CLP01 must be identical to any value received as a Claim Submitter’s Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable).”

The Replacement submission is identified by a Claim Frequency Type Code value of ‘7’ and is not considered an ORIGINAL or a new ORIGINAL. There may be multiple Replacements submitted, each with a different substantive change of some type, as you describe in the scenario. None of the Replacement submissions is considered to be an ORIGINAL but are presumed to tie back to the ORIGINAL.
Therefore, when adjudicating a replacement to an original claim the CLP01 must be the value of the CLM01 of the original claim.

The recommendation in RFI 1799 related to voided claims would also apply to replacement claims. The recommendation is that the value in the CLM01 of any Replacement claim should be identical to the value sent in the Original claim.
Submission 6/27/2014
Status Date 8/4/2014
Status F - Final
Primary References
Document 005010X221A1
SectionNone
Loop2300
Segment Position0100
Segment IDCLP
Element Position01