Section title: Requests for Interpretation
835 CLP02: Claim Status Code 2

Can Claim Status 2, "Processed as Secondary be used when a payer has determined there may be Coordination of Benefits, but not confirmed?


There is a possibility that there may be a primary payer, a letter has been sent to the member to confirm but has not yet been returned.  The claim is then denied PR22, this care may be covered by another payer per coordination of benefits.  Should the CLP02 in this case be a '2' processed as secondary or a '1' processed as primary?

RFI Response

If uncertain that another payer is primary, use of claim status code 2 would not be appropriate.  Use of claim status code 2 in the CLP02 is required when the claim was adjudicated by this payer as secondary.  When the claim is received as primary and the payer is unable to determine the priority payer, the claim would be processed with a status code of 1.