Health Care Claim Status Category Codes

$79 / year

This dataset explains the Claim Status Category Codes that indicate the general category of the status (accepted, rejected, additional information requested, etc.) which is further detailed in the Claim Status Codes.

Complexity

The HIPAA or Health Insurance Portability and Accountability Act of 1996, instructs medical healthcare plans to use the standard electronic transactions adopted under this agency by using the following valid standard codes.
Medicare policy requires that Claim Status Category Codes should provide a general description of each claim. If a detailed explanation is required, the Claim Status Codes will be referenced for further information on the status of a claim.

The Centers for Medicare & Medicaid Services (CMS) maintain and annually update a List of Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) Codes (Code List), which identifies all the items and services included within certain DHS categories. CMS updates the Code List to conform the list to the most recent publications of CPT and HCPCS and to account for changes in Medicare coverage and payment policies. The updated Code List is published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. That rule is usually published in November and generally becomes effective January 1 of the following year. In addition, we may publish other rules or correction notices that may change the Code List. CMS posts any changes to the Code List on its webpage as soon as possible after publication in the Federal Register.

The DHS categories defined by the Code List are:
– Clinical laboratory services;
– Physical therapy services, occupational therapy services, outpatient speech-language pathology services;
– Radiology and certain other imaging services; and
– Radiation therapy services and supplies.

**NOTE**: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:
– Durable medical equipment and supplies;
– Parenteral and enteral nutrients, equipment and supplies;
– Prosthetics, orthotics, and prosthetic devices and supplies;
– Home health services;
– Outpatient prescription drugs; and
– Inpatient and outpatient hospital services.

Date Created

1995

Last Modified

2017-03-07

Version

2017-03-07

Update Frequency

Irregular

Temporal Coverage

1995-2015

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Claim status category codes, CSCC, ASC X12 External Code Source 507, Claims Adjudication, Disposition Codes

Other Titles

Health Insurance Portability and Accountability Act (HIPAA) standard electronic transactions, Medicare appropriate Claim Status Category Codes, General explanation of claim status codes, General category of Claim Status Category Codes, Claims Adjudication and Claim Status Category Codes, Disposition Codes and Claim Status Category Codes

Name Description Type Constraints
CodeClaim Status Category Codesstringunique : 1 required : 1
DescriptionDescription for each Claim Status Category Codestringunique : 1 required : 1
CategoryCategory of the Claim Status Category Codesstringrequired : 1
Start_DateDate the Claim Status Category Code started usagedaterequired : 1
Last_ModifiedDate the Claim Status Category Code was changed/modifieddate-
Stop_DateDate the Claim Status Category Code was deactivated/stoppeddate-
StatusCode update whether Active, To be Deactivated or Deactivatedstringrequired : 1
NotesExplanation to redundant and/or replacement Claim Status Category Codestring-
CodeDescriptionCategoryStart_DateLast_ModifiedStop_DateStatusNotes
E1Response not possible - System StatusError2000-02-29Active
P5Pending/Payer Administrative/System holdPending2006-10-31Active
X0Supplemental MessagesSupplemental1995-01-012003-10-16Deactivated
F5Finalized/Cannot ProcessFinalized1995-01-012003-10-16Deactivated
E3Correction required - relational fields in error.Error2010-01-24Active
F1Finalized/Payment-The claim/line has been paid.Finalized1995-01-01Active
F2Finalized/Denial-The claim/line has been denied.Finalized1995-01-01Active
E2Information Holder is not responding; resubmit at a later time.Error2003-06-30Active
F3Finalized/Revised - Adjudication information has been changedFinalized2001-02-28Active
E0Response not possible - error on submitted request dataError1995-01-012002-02-28Active