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Back  RFI # 207: 835 CLP02

Formal vs. Informal Help Informal Formal

Submitter

Mary Butler

Description

On the 835 for Loop 2100 CLP02 would like to have clarification on when a 4 (denied) would be used versus a 1 (for Processed as primary). Our interpretation is that we are still processing the claim as primary even if we are denying the whole claim and the providers should be looking in the CAS segments for the appropriate group code and adjustment reason codes for the denial.

Response

The authors of the 835-implementation guide agree with your interpretation. You succinctly state the intent of CLP02 and qualifier 4. However usage of CLP02 and Claim Status Code 4 is not clearly defined in 4010A1. Therefore, usage of Claim Status code 4 to indicate a denial of a claim is not wrong.

Recommendation

Later versions of the 835-implementation guide clarify the intent of CLP02 and specifically address Claim Status Code 4.
Submission 2/18/2005
Status Date 4/19/2005
Status F - Final
Primary References
Document 004010X091A1
SectionLoop 210
Page90
Set IDCLP02