Section title: Requests for Interpretation
RFI #
2398
Replacement Claims - RARC N142
Description

Per the NUCC CMS-1500 and ASC-X12 837 standards, replacement claims should be submitted with indicators to reflect the fact that they are replacement claims to an original, already submitted claim. Specifically, in the 837 file, CLM05 – 3 – 1325 Claim Frequency Code is to be populated with a “7” to indicate a replacement claim, and REF02 – 127 – F8 Payer Claim Control Number is to be populated with the original claim’s ICN. Both fields are considered required, per X12 837 standards. X12 has also created 835 Remittance Advice Remark Code (RARC) N142 – The original claim was denied, resubmit a new claim, not a replacement claim. If all replacement claims are to be submitted with the aforementioned indicators reflecting the fact that they are replacement claims, in what scenario would it be appropriate for a payor to deny a replacement claim instructing a provider to submit a new claim instead? As you can see, it seems the X12 837 replacement claim requirements conflict with the X12 835 RARC of N142.

Response

It is not within X12’s purview to comment on the usage of a Remittance Advice Remark Code as X12 does not own this code list.   We also cannot comment on a payer’s policy or procedure for denying claims and the usage of adjustment codes. It could be appropriate for a payer to deny a replacement claim when their system does not allow replacement of denied claims. This should be noted in the trading partner agreement, their applicable Companion Guides or other policy available to the provider.

RFI Recommendation

Contact the payer directly to review their Companion Guide or other policy available to the provider.

DOCUMENT ID
005010X222A1