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Back  RFI # 437: Pended claim /ERA

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Submitter

Richard Firestone

Description

Please assist me in responding to a providers request. We are working for a payer and a large provider is asking us to modify our systems processing to communicate Pended claim information in the ERA transaction. Can you tell me if we do this - would we be out of compliance?
We are also told that many other payers are doing this for them.

Submitter Assigned Keywords

pended claims era

Response

This issue is explicitly addressed in guide 004010X091. CLP02 (Claim Status Code) value "5" is described as "Pended" and has a note that reads "Claims with this status should be reported in the Claim Status (277) transaction when the payer implements it." While that code is Not Advised, its usage is valid under this guide. Usage would require appropriate CAS segments to reduce the balance to $0. We recommend using a CAS01 code of "OA" (other Adjustment) and a CAS02 code of "133" (The disposition of this claim/service is pending further review).

Recommendation

CLP02 qualifier 5 has been removed from the next version of the guide and will not be available for use. The workgroup strongly recommends that this qualifer not be used.
Submission 8/1/2006
Status Date 9/8/2006
Status F - Final
Primary References
Document 004010x091a1
SectionUnknown
Page??
Set ID835