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Back  RFI # 879: ClaimStatusCode for Late Claim

Formal vs. Informal Help Informal Formal

Submitter

Kevin Waite

Description

I work on behalf of a Provider Portal and for one of our Health Plan Partners, one of their more frequent reasons for denying a claim is when a Provider does not submit their claim in the required time frame. However, there is no Claim Status Code (or even Category Code) that would indicate that this was the reason why a claim was Denied.

What is the best Claim Status Code to use if a claim was denied because the claim was not submitted within the required time frame?

Response

The ASC X12N/TG2/WG5 (Claim Status) workgroup has reviewed the code list and agrees there is not currently a Claim Status Code that adequately addresses the denial of a claim for timely filing. Any entity may submit requests for new or revised Claim Status Codes based on business need. Those requests are reviewed and a determination is made on the request three times per year by the Code Committee. The next meeting of the Code Committee will be held on January 24, 2010.

Recommendation

The Claim Status workgroup recommends the submitter request a new Claim Status Code specific to ‘Timely Filing’. The request must be generated through an online submission process located under Code Lists, Health Care Claim Status Codes, at the following website: http://www.wpc-edi.com. The request must be submitted prior to January 13, 2010 for consideration at the next meeting.

In the interim, the workgroup recommends use of Claim Status Codes 104 or 107, depending on the provision being invoked (i.e. Contract or Plan provision).
Submission 10/7/2009
Status Date 11/20/2009
Status F - Final
Primary References
Document 004010X093
SectionL 2200D
Page154
Set IDSTC
Segment IDSTC
Element Position01
Component Position2
External Code ListClaim Status Code