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Formal vs. Informal Help Informal Formal

Submitter

michael saville

Description

We receive 835 transmissions from an insurance company. They have many PPO and HMO insurance coverages and pass values 12 and 16 for all plans as specified in the manual. However, I believe the CLP06 field is intended to differentiate between the plans and is not restricted to the plan type. The payer should provide their own code to distinguish between HMO plan 1 and HMO plan 2. The provider would need to translate the payer's code to the appropriate code used by the provider.

Response

This issue is explicitly addressed in guide 004010X091. Page 92 specifically identifies CLP06 as an ID type data element with an internal code lists. Values other than those listed in the guide are not permitted. Identification of the specific payer's network, contract or plan are provided in the Other Claim Identifier REF segment on page 126 using REF01 code value CE (Class of Contract Code).

Recommendation

Additional information about Class of Contract code usage can be found in the 4050 version of the 835 guide (004010X124) in section 2.2.15 (PPOs, Networks and Contract Types). This guide can be obtained from www.wpc-edi.com for a nominal fee.
Submission 4/6/2005
Status Date 4/8/2005
Status F - Final
Primary References
Document 004010x091A1
Section3.1
Page92
Set ID835
TableD
Loop2100
Segment Position010
Segment IDCLP
Element Position06
Industry NameClaim Filing Indicator Code