Health Care Claim Status Codes

$447.50 / year

Health Care Claim Status Codes convey the status of an entire claim or a specific service line. Claim status codes communicate information about the status of a claim, i.e., whether it’s been received, pended, or paid. The Claim Status transaction is not used as a financial transaction.

Complexity

Claim Status Codes are used in the Health Care Claim Status Notification (277) transaction in the STC01-2, STC10-2 and STC11-2 composite elements. They indicate the detail about the general status communicated in the Claim Status Category Codes carried in STC01-1, STC10-1 and STC11-1.

The Centers for Medicare & Medicaid Services (CMS) staff usually requests changes in the code when it directly affects the Medicare policy. Shared System Maintainers (SSMs) and Medicare contractors are notified about all the necessary changes. If a modification has been implemented by an entity outside CMS for a code currently used by Medicare, Medicare Administrative Contractors (MACs) must either use the existing modified code or another code. If any new or modified code has an effective date past the implementation date specified in CR9004, MACs will implement on the date specified on the WPC website.

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

2020-03-01

Version

2020-03-01

Update Frequency

Irregular

Temporal Coverage

1995 to 2019

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare and Medicaid Services;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Claim Status Code, United Healthcare Payment, ASC X12 External Code Source 508, Status of Medicare Claims, Health Care Claim Status Notification, Claims Adjudication, Disposition Codes, Medicare Billing Codes, Medicare Claim

Other Titles

Health Insurance Portability and Accountability Act (HIPAA) Standard Electronic Transactions, Medicare Appropriate Claim Status Codes, Claim Status Codes Explanation for Specific Service Lines, Health Care Claim Status Notifications, Claims Adjudication and Claim Status Codes, Disposition Codes and Claim Status Codes

NameDescriptionTypeConstraints
CodeClaim Status Codesintegerlevel : Nominal required : 1
DescriptionDescription for each Claim Status Codestringrequired : 1
Start_DateDate the Claim Status Code started usagedaterequired : 1
Last_ModifiedDate the Claim Status Code was changed/modifieddate-
Stop_DateDate the Claim Status Code was deactivated/stoppeddate-
StatusCode update whether Active, To be Deactivated or Deactivatedstring-
NotesExplanation to redundant and/or replacement and other important changes to the Claim Status Codestring-
CodeDescriptionStart DateLast ModifiedStop DateStatusNotes
0Cannot provide further status electronically.1995-01-01Active
1For more detailed information, see remittance advice.1995-01-01Active
2More detailed information in letter.1995-01-01Active
3Claim has been adjudicated and is awaiting payment cycle.1995-01-01Active
4This is a subsequent request for information from the original request.1995-01-012008-01-272008-07-01Deactivated
5This is a final request for information.1995-01-012008-01-272008-07-01Deactivated
6Balance due from the subscriber.1995-01-01Active
7Claim may be reconsidered at a future date.1995-01-012008-01-272008-07-01Deactivated
8No payment due to contract/plan provisions.1995-01-012007-07-092008-01-01Deactivated
9No payment will be made for this claim.1995-01-012008-01-272008-07-01Deactivated