Carrier Claim Payment Denial Code
The code on a non-institutional claim indicating to whom payment was made or if the claim was denied.
Effective with Version 'J', the field was expanded on the NCH record to 2 bytes, With his expansion, the NCH will no longer use the character values to represent the official two byte values sent in by NCH since 4/2002. During the Version J conversion, all character values were converted to the two byte values.
On 4/1/02, this field was expanded to two bytes to accommodate new values. The NCH Nearline file did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte character value.
This variable is coded, and will contain one of the following values.
Only one-byte was used until 1/2011 (currently, either 1 or 2-byte values may be used, symbols not currently allowed)
| Value | Description |
|---|---|
0 |
Denied |
1 |
Physician/supplier |
2 |
Beneficiary |
3 |
Both physician/supplier and beneficiary |
4 |
Hospital (hospital based physicians) |
5 |
Both hospital and beneficiary |
6 |
Group practice prepayment plan |
7 |
Other entries (e.g. Employer, union) |
8 |
Federally funded |
9 |
PA service |
A |
Beneficiary under limitation of liability |
B |
Physician/supplier under limitation of liability |
D |
Denied due to demonstration involvement |
E |
MSP cost avoided IRS/SSA/HCFA Data Match (after 01/2001 is First Claim Development) |
F |
MSP cost avoided HMO Rate Cell (after 1/2001 is Trauma Code Development) |
G |
MSP cost avoided Litigation Settlement (after 1/2001 is Secondary Claims Investigation) |
H |
MSP cost avoided Employer Voluntary Reporting (after 1/2001 is Self-Reports) |
J |
MSP cost avoided Insurer Voluntary Reporting (eff. 7/3/00) |
K |
MSP cost avoided Initial Enrollment Questionnaire (eff. 7/3/00) |
P |
Physician ownership denial |
Q |
MSP cost avoided - voluntary agreements including with employer |
T |
MSP cost avoided - Initial Enrollment Questionnaire |
U |
MSP cost avoided - HMO rate cell adjustment |
V |
MSP cost avoided - litigation settlement |
X |
MSP cost avoided – generic |
Y |
MSP cost avoided - IRS/SSA data match |
00 |
MSP cost avoided - COB Contractor |
12 |
MSP cost avoided - BC/BS Voluntary Data Sharing Agreements (VDSA) |
13 |
MSP cost avoided - Office of Personnel Management (OPM) Data Match |
14 |
MSP cost avoided - Workman's Compensation (WC) Data Match |
15 |
MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) |
16 |
MSP cost avoided - Liability Insurer VDSA |
17 |
MSP cost avoided - No-Fault Insurer VDSA |
18 |
MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement |
21 |
MSP cost avoided - MIR Group Health Plan |
22 |
MSP cost avoided - MIR non-Group Health Plan |
25 |
MSP cost avoided - Recovery Audit Contractor – California |
26 |
MSP cost avoided - Recovery Audit Contractor – Florida |
41 |
MSP cost avoided - non-Group Health Plan non-Ongoing responsibility for medical (ORM) |
43 |
MSP cost avoided - Medicare Part C/Medicare Advantage |
Prior to 2011, the following 1-byte character codes were also valid (these characters preceded use of 2-byte codes, above):
| Value | Description |
|---|---|
! |
MSP cost avoided - COB Contractor (converted to '00' 2-byte code) |
@ |
MSP cost avoided - BC/BS Voluntary Agreements (converted to '12' 2-byte code) |
# |
MSP cost avoided - Office of Personnel Management (converted to '13' 2-byte code) |
$ |
MSP cost avoided - Workman's Compensation (WC) Datamatch (converted to '14' 2-byte code) |
* |
MSP cost avoided - Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC VDSA) (eff. 4/2006) (converted to '15' 2-byte code) |
( |
MSP cost avoided - Liability Insurer VDSA (eff. 4/2006) (converted to '16' 2-byte code) |
) |
MSP cost avoided - No-Fault Insurer VDSA (eff. 4/2006) (converted to '17' 2-byte code) |
+ |
MSP cost avoided - Pharmacy Benefit Manager Data Sharing Agreement (eff. 4/2006) (converted to '18' 2 -byte code) |
< |
MSP cost avoided - MIR Group Health Plan (eff. 1/2009) (converted to '21' 2-byte code) |
> |
MSP cost avoided - MIR non-Group Health Plan (eff. 1/2009) (converted to '22' 2-byte code) |
% |
MSP cost avoided - Recovery Audit Contractor - California (eff. 10/2005) (converted to '25' 2-byte code) |
& |
MSP cost avoided - Recovery Audit Contractor - Florida (eff. 10/2005) (converted to '26' 2-byte code) |
Some additional information on this variable: