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Back  RFI # 288: Reprocessed reversed claims

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Submitter

Janice Cunningham

Description

I am asking this because I am being told by a payer that the way they are reporting reprocessed claims is compliant and I need assistance showing it is not compliant.
When a claim is being reversed and the money taken back the claim is being reported with Claim Status of 22, which is correct as code 22 is "Reversal of Previous Payment."
When the claim is reported as reprocessed (corrected) and either paid or denied the claim is being reported with Claim Status of 22. Since the claim is not a reversal, code 22 would not be correct. The claim should be reported with a Claim Status Code that correctly states the actual status of the claim.
Could you please verify this?

Submitter Assigned Keywords

Claim Status on reprocessed claims

Response

This issue is explicitly addressed in guide 004010X091 in the Reversal and Corrections section (2.2.8). That section states "The corrected claim payment is provided as if it were the original payment." The example of a corrected claim also includes "CLP*1234567890*1*100*24*36*12~". This example shows a Claim Status of 1 (Processed as Primary".

You are correct. Use of code 22 in CLP02 for the correction part of the reversal and correction process is not consistant with the guide.
Submission 7/28/2005
Status Date 7/29/2005
Status F - Final
Primary References
Document 004010X091A1
Section2001 clp
Page89
Set IDCLP02
Loop2100
Segment IDclp
Element Position02