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Back  RFI # 546: 835 CLP02 Claim Status Code

Formal vs. Informal Help Informal Formal

Submitter

chip dycio

Description

We are receiving 835 remittance files from a Medicaid payer. In field CLP02, the payer is returning claim status code ‘3’ (processed as tertiary) for all payments, regardless of how the claim was submitted for payment. Medicaid does not use claim status ‘1’ (processed as primary) even if Medicaid is the only payer for the patient. Nor does Medicaid use claim status ‘2’ (processed as secondary).
We contacted Medicaid to ask why they only use a status code of ‘3’ for payments. They responded by saying they consider themselves the payer of last resort and therefore will always value CLP02 with ‘3’, even if the patient has no other insurance. This appears to be an incorrect usage of CLP02. If Medicaid is the only payer for the patient and the claim was submitted to Medicaid as the primary and only payer, shouldn’t Medicaid value CLP02 on the 835 with ‘1’? Likewise, if the patient has one other insurance in addition to Medicaid and Medicaid is the secondary payer, shouldn’t Medicaid value CLP02 with 2?

Submitter Assigned Keywords

835 CLP02 claim status code

Response

This issue is explicitly addressed in guide 004010X091. The values in CLP02 are "Processed as primary" (1), "Processed as secondary" (2) and "Processed as Tertiary) (3). These represent a processing order by payer, and must be used that way. Redefining "Processed as Tertiary" to be "Payer of last resort" is not allowed per section 1.1.1 which states that trading partner agreements can NOT "Modify the definition, condition, or use of a data element or segment in the standard Implementation Guide" or "Change the meaning or intent of this Implementation Guide".
Submission 4/13/2007
Status Date 5/4/2007
Status F - Final
Primary References
Document 004010X091A1
Section3.1
Page89
Set ID???
TableD
Loop2100
Segment Position010
Segment IDCLP