Variable: CLM_AUDT_TRL_STUS_CD

Claim Status Code

Description:

The current status information for the pending and paid claims currently in the system. Augmented to derive using system type + location code + status code.

Values

This variable is coded, and will contain one of the following values.

Value	Description
FS	A manual update is needed before the claim processing can continue.
FD	Claim has reached final disposition with no reimbursement (medical denial).
FP	Claim has reached final disposition with reimbursement.
FR	Claim has reached final disposition with no reimbursement (non-medical reject).
FT	Claim has reached final disposition with no reimbursement and has been returned to the provider with billing errors.
FI	Claim moves from the active processing file to the inactive file.
MA	Current active claim. This is an internal MCS MPAP status, and will only display online in related history.
MB	Suspended. All pending claims will show this status when they are viewed online. All other pending claim statuses are used internally by MCS MPAP only.
MC	Approved awaiting CWF response through MPAP, claim processed with no outstanding edits/audits through MPAP and queried.
MD	Approved and paid; CAP physician no pay detail lines.
ME	Denied; set based on the history usage indicator on the AA segment of a denial edit or audit.
MF	Full claim refund - EGHP, used only when an EGHP accounts receivable has been satisfied (RG type AR). This status is for display purposes only, internally the claim status would be a ‘y’.
MG	Partial refund applied, partial refund was calculated for the claim but was applied to something else outstanding, such as an AR.
MJ	Claim still active. This is an internal MCS MPAP status, and will never display online.
MK	Claim in pending suspense, used as history for duplicate audits but not MPAP (relationship or negative relationship audit). This is an internal MCS MPAP status, and does not display online except as related history or on a bene research document (BRD). The status can be set several ways: claim has no significant claim-level audit failed, but has claim-level edit suspense (does not look at history usage on edit) claim or detail suspends for a post-CWF audit detail suspends with ‘f’ disposition audit that has a history usage of ‘3’
ML	CWF suspense, no MPAP, the HIC change trailer on the claim has a different cross-reference HIC than the ‘h’ trailer on eligibility. Note: the ‘L’ status is an internal status and will not appear on a claim. While the HIC is being changed, the claim will have an ‘L’ status until the change is complete.
MM	Approved and paid (includes all deductible) - currently not used.
MN	Denied for payment (excludes deductible), set based on the history usage (AA segment) indicator on a denial edit or audit.
MP	Partial claim refund - EGHP, used only when an EGHP accounts receivable has been satisfied (RG type AR). This status is for display purposes only, internally the claim status would be a ‘g’.
MQ	Adjusted - claim has been replaced by a full claim adjustment.
MR	Claim has been deleted from the system. When a claim is deleted (transferred to location 090), the claim status and the detail status are both set to ‘R’.
MU	Paid but not for dup use - currently not used.
MV	Denied, but not for dup use, set based on the history usage indicator on the AA segment of a denial edit or audit.
MW	Rejected. This status is set for Assigned and Non-Assigned claims, based on the receipt date, the bene submission form, and the reject indicator which is MSG ACTION = RJ or R2 on the Narrative Message Usage file (NA). If all details are rejected (status ‘W’) then the claim status is set to rejected (‘W’).
MX	Partial refund, claim that is a partial void and a split pay.
MY	Full refund, full amount of claim payment was returned.
MZ	Voided, full void has been issued for the claim.
M1	Current active claim, separate history. This is an internal MCS MPAP status, and will only display online in related history. This status applies to the header of claims that contain a demonstration number that has been flagged for separate history in the HXXTDEMO table.
M2	Suspended, separate history. All pending claims will show this status when they are viewed online. All other pending claim statuses are used internally by MCS MPAP only. This status applies to the header of claims that contain a demonstration number that has been flagged for separate history in the HXXTDEMO table.
M3	Approved awaiting CWF response, separate history, through MPAP, claim processed with no outstanding edits/audits through MPAP and queried. This status applies to the header of claims that contain a demonstration number that has been flagged for separate history in the HXXTDEMO table.
M4	Approved and paid, separate history. This status applies to the header of claims that contain a demonstration number that has been flagged for separate history in the HXXTDEMO table.
M5	Denied; separate history, set based on the history usage indicator on the AA segment of a denial edit or audit. This status applies to the header of claims that contain a demonstration number that has been flagged for separate history in the HXXTDEMO table.
M6	Not Used
M8	Claim moved to another HIC. Claim was submitted and finalized for a HIC prior to the HIC being changed. (This status is internal to MCS only and will not display online.)
M9	Claim deleted from system. Claim deleted from MPAP due to rework, the ICN is a duplicate of another ICN in the system. (This status is internal to MCS only and will not display online.)
V0008	Void/Entry Code 3 Claim
V0105	TPL Suspense/MSP/HMO (Jurisdiction D’s HMO claims suspend to 09/27)
V0109	TPL Suspense/MSP/HMO (Jurisdiction D’s HMO claims suspend to 09/27)
V0107	MSP Cost Avoid
V0207	MSP Denied Lines
V0209	MSP claims that received CWF edit 6819 and had non-GHP MSP prior to querying CWF
V0306	Purged
V0307	MSP Split Claims
V0309	MSP claims that received CWF edit 6819 and did not have non-GHP MSP prior to querying CWF
V0405	Clean claim (ready to adjudicate)
V0505	Line item error
V0506	Line item error
V0509	If the system cannot identify a VMS Action Code; the claim suspends to this location/status for review. You need to verify that the FPS Model Number on each claim line appears on the VMAP/4C/ACFPWALK table. If the FPS Model Number/Action Code combination is not on the table, update the table according to the TDL issued by CMS that introduced the FPS Model. After updating the table, deny the claim line or lines as follows: • Type the Action Code for the FPS Model Number on the claim line or lines. • Ensure that the Allowed Amount on the claim is zero. • Type R in the Claim Review Code field. Refer to entries for FPSD and FPSH in the APEX Reference Manual in the chapter on “Common Working File (CWF) Codes” for additional information.
V0606	Provider problem
V0706	Medical consultation
V0805	Edit error
V0806	Edit error
V0905	Specialty examination
V0906	MSP with a primary paid amount from the primary payer
V1004	Delete
V1105	Claim referred to supervisor
V1202	MSP first letter initiated
V1302	Suspense – Other
V1404	Suspense – DME
V1405	Suspense – DME
V1505	Chiropractor claim
V1602	MSP first letter sent
V1701	Activated; not entered
V1802	Utilization review
V1807	Utilization review
V1809	Utilization review
V1907	Third level review (prior history review)
V2005	Reject name/sex
V2104	Adjustment
V2205	Entitlement termination; quality control
V2305	No beneficiary address
V2404	Beneficiary BUDS01 record closed
V2405	Beneficiary BUDS01 record closed
V2409	Beneficiary BUDS01 record closed
V2508	Representative payee
V2509	Representative payee
V2608	Welfare; Disposition Code 42
V2609	Welfare; Disposition Code 42
V2708	Services prior to entitlement (HMO for Jurisdiction D only)
V2709	Services prior to entitlement (HMO for Jurisdiction D only)
V2804	Mass adjustment suspensions
V2906	Missing data
V3004	Location/status 04/30 is for estimated interest errors. Batch adjudication program VMSCW273 generates this location/status prior to sending the claim to CWF, based on the absence of valid data in certain fields on the claim. These fields include: the date of receipt, the estimated mail date, the amount paid to the provider, the amount paid to the beneficiary, the provider participation indicator, and the provider specialty.
V3005	Location/status 04/30 is for estimated interest errors. Batch adjudication program VMSCW273 generates this location/status prior to sending the claim to CWF, based on the absence of valid data in certain fields on the claim. These fields include: the date of receipt, the estimated mail date, the amount paid to the provider, the amount paid to the beneficiary, the provider participation indicator, and the provider specialty.
V3105
V3305	Reasonable charge
V3405	Physician inactive/missing
V3505	Physician utilization
V3602	MSP first letter follow-up
V3707	Duplicate suspect
V3807	Beneficiary utilization - mandatory assignment for drugs/biologicals
V3902	Beneficiary information
V3907	Rebundled claims (Jurisdictions A, B, & C)
V4009	Premium arrearage; V trailer
V4108	New jurisdiction; E trailer; Disposition Code 40
V4109	New jurisdiction; E trailer; Disposition Code 40
V4208	Unique for CWF resubmits – deny after 4 or 20 days, as appropriate
V4209	Unique for CWF resubmits – deny after 4 or 20 days, as appropriate
V4308	Reply Disposition Code 43
V4309	Reply Disposition Code 43
V4402	MSP automated development
V4408	MSP automated development
V4508	Name error
V4509	Name error
V4603	Normal DME record (Cert)
V4707	Re-suspend the claim from a UR LL/SS; AC operator did not type review code U showing UR review is complete
V4709	New HICN; C trailer
V4807	Re-suspend the claim from a UR LL/SS; the PSC/ZPIC operator did not type review code U showing UR review is complete
V4809	Worker’s Compensation; Y trailer
V4907	Rebundling (Jurisdiction D only)
V4909	Reject Travelers, RRB, or UMW
V5003	Stale cert – automated DME
V5005	Stale cert – automated DME
V5103	Stop cert – automated DME
V5205	Reasonable charge error
V5206	Reasonable charge error
V5305	No cert on file – automated DME
V5408	Alien no pay
V5509	Hospice involvement
V5608	Adjustment claim error/09 entry code
V5609	Adjustment claim error/09 entry code
V5702	Initiate MSP development
V5705	Initiate MSP development
V5707	LMRP/NCD denial by a non-MR edit that is missing LMRP/NCD numbers
V5709	LMRP/NCD denial by CWF that is missing LMRP/NCD numbers
V5807	LMRP/NCD denial by a non-MR edit that is missing LMRP/NCD numbers
V5802	Generate the MSP letter
V5902	Eligible for denial for MSP
V5905	Eligible for denial for MSP
V6004	Excess history
V6104	Beneficiary paid
V6204	System error
V6209	When a claim/CMN has an address that CWF cannot format, CWF returns it with Trailer 12. If the claim/CMN has a 01 disposition, VMS suspends it to this location/status. VMS prints UNFORMATTED in the CITY field of the CW4101-SSA BENE ADDRESS ERROR LISTING REPORT. You must resolve the address problem on the BUDS01 record and type address flag AR in the AF field so that VMS does not update the record with subsequent address information from CWF. After you correct the address, VMS resends the claim/CMN to CWF with Entry Code 05. CWF returns the claim/CMN with an 01 disposition. If applicable, VMS updates the claim/CMN with the correct payment information and processes it to location 10.
V6304	Excess splits
V6402	Development non-response
V6502	Development initiated
V6602	Development sent
V6702	Development follow-up sent
V6802	Referral initiated
V6902	Referral generated
V7002	Referral sent
V7102	Follow-up referral generated
V7202	Follow-up referral sent
V7302	Referral non-response
V7402	ADS manual status
V7500	Paid
V7508	Claim failed the CARC/RARC/Group Code validation program Claim reprocesses daily through the CARC/RARC/Group Code validation program and moves to location 10 after the validation program makes a successful validation of the claim’s CARCs, RARCs, and Group Codes.
V7600	Not paid, all or partially paid to deductible
V7608	Claim failed the CARC/RARC/Group Code validation program Claim reprocesses daily through the CARC/RARC/Group Code validation program and moves to location 10 after the validation program makes a successful validation of the claim’s CARCs, RARCs, and Group Codes.
V7700	Denied
V7708	Claim failed the CARC/RARC/Group Code validation program Claim reprocesses daily through the CARC/RARC/Group Code validation program and moves to location 10 after the validation program makes a successful validation of the claim’s CARCs, RARCs, and Group Codes.
V8009	A/B crossover edits
V8109	Mammography, pap smear, or cataract lens claims adjusted with Entry Code 3
V8309	An Oxygen Equipment claim processing against a CMN with the maximum number of rentals in an open status causes the claim to suspend to this location/status. The CMN remains in an open status and the system makes no changes to the rental count of the CMN. Until corrective action is performed, claims continue to suspend to this location/status. Options for corrective action on the CMN are: • Close the CMN • Manually reduce the number of rental payments
V8407	Global surgery
V8500	Claim received back from HIGLAS with check number
V8507	Multiple surgery with UT error, auto denial
V8509	DOD/REP
V8607	E/M location
V8609	UR 11 rejects
V8700	Claim sent to HIGLAS on the 837 Interface file
V8709	UR 08 rejects
V8809	Name incorrect
V8908	Acknowledgment (Disposition Code 09)
V9003	OQC
V9007	Batch repricing process
V9008	Reply Disposition Code 90
V9103	OQC
V9203	OQC
V9403	OQC
V9503	OQC
V9508	S, M, G query
V9603	OQC
V9608	T, N, H query
V9609	CWF Error
V9703	OQC
V9708	R, L, I query
V9803	OQC
V9808	Resend to CWF
V9903	OQC
V9904	Duplicate claim
V9908	Regular – Entry Code 1 and follow-up claims to CWF