Section title: Requests for Interpretation
RFI #
2365
CLP02 1 vs 19
Description

We have a situation where a patient has a duel enrollment plan, so they have a primary and secondary plan with a specific payer. In this instance, the payer processes and pays the primary claim, and processes and pays the secondary claim without us needing to send a secondary claim. Essentially they forward it to themselves. The issue is when they send the primary payment, they send a CLP02 value of 1 instead of 19.

Their justification for this is the spec says "Forwarded to Additional Payer(s)", and since they are the same payer they dont need to use the 19. Since they have two different coverage's and are forwarding the claim to themselves, i believe they would need to us the 19 instead.

Can you tell me if their interpretation is out of compliance?

Response

The 835 can report dual enrolled primary plan as follows:
CLP02 value 19 can be reported when the payer is forwarding the claim within the same payer organization to another plan/product or to another payer entity. The value 19 communicates to the provider that they do not need to resubmit the claim.

CLP02 value 1 is allowable since the claim is moving within the payer organization. It is the responsibility of the payer to communicate to their providers in a companion guide/provider manual so the provider knows not to resubmit the claim again.

DOCUMENT ID
005010X221