Section title: Requests for Interpretation
RFI #
2416
CLM01
Description

CLM01 Loop 2300 - provider submits their patient account number in CLM01. The payer process and sends 835/payment (if applicable to the provider. The payer submits the payer's claim number in the CLM01 and submit encounter to the state/gov. PG 160 CLM01 837P 5010; the submitter sends the claim or patient number in the clm01. Considering the payer becomes the submitter when submitting the encounter to the state/gov. Can the payer use their claim number when submitting the encounter to the state or must they use the providers claim/patient number; when the provider submits the encounter to the state?

Response

The current guide’s CLM01 data element is defined as Claim Submitter’s Identifier with the Implementation Name of Patient Control Number.  The 005010X222A1 837 which you inquired about does not limit or restrict the value that can be sent in this data element, beyond the element’s name.  The data element note 1 states ‘…this field as a key in the submitter’s system to match the claim to the payment information…’ As the submitter, the claim number from your system would meet this guidance. The 837 does contain a REF segment in the 2300 loop for the Payer Claim Control Number but this REF segment in the 005010X222A1 is restricted to identifying replacement or void claims.

RFI Recommendation

When exchanging encounter data it is recommended payers consider using the applicable Post Adjudicated Claims Data Reporting (PACDR) 837 transaction.   If you have a business need not supported in a published TR3, you may submit an ASC X12 change request for consideration in a future version of the TR3. Change requests are submitted at

http://changerequest.x12.org

DOCUMENT ID
005010X222A1