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Formal vs. Informal Help Informal Formal


Jennifer Delmont


Is it the intent of the authors that the payor assigned CLP06 value should take precedence over the value assigned by the provider in SBR09?

If a provider sends HMO in SBR09 but the member is enrolled in an indemnity product we feel our 835 should reflect indemnity in CLP06 and not HMO. However, our vendor is moving the value from SBR09 even though we assigned something different during adjudication.

Thank you

Submitter Assigned Keywords



This issue is explicitly addressed in guide 004010X091. The element note on CLP06 states "The value should mirror the value received in the original claim (2-005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer." If the payer changes the product to match the subscriber's correct coverage, then the value submitted by the provider is no longer applicable. Therefore, yes - it is the intent that the payer assigned value take precedence over the provider submitted value.
Submission 10/4/2005
Status Date 10/10/2005
Status F - Final
Primary References
Document 004010X091A1
Segment IDCLP
Element Position06