The ERA recognizes 5010 compliant claim status codes. It matches on payer based upon the hierarchy of Payer Nbr, Policy nbr, and Claims Status.
When the claim status equals 4, the application reads the version number of the 835 and determines if it is a 5010 claim. It then automatically posts the transactions with an Appeal / Skip ERA Adjustment status. The ERA Import Posting report displays the following message: "Line Item Successfully Posted - Patient/Subscriber is not recognized by the Ins".
If "Never" is selected in the Remittance Profile Library, the 0.00 payment is not posted. In this case, the ERA Import Posting displays the following message: "Not Posted - Patient/Subscriber is not recognized by the Insurance".
When Claim Status does not match the correct COB, the application:
- Does not post payments when Claim Status Indicator does not match the correct bucket.
- The ERA Import Posting report displays the following message: "Payment not posted due to Claim Status Indicator not matching COB".
5010 Claim Posting
The Primary posting functionality includes a claim status of 1 or 19, which can indicate payment by the primary payer. The same indicator can also be represented when the primary payer has denied a service line.
The following 5010-related conditions apply when
CLP02 = 1 with a payment amount equal to $0.00:
- If the Post zero line item payments option in the Remittance Profile Library is set to Always, then the application follows the transaction detail status of the Reason Code returned in the CAS segment. For example, if CO96 is set to Appeal and Skip Adjustment, the application follows these rules to keep the balance in the primary bucket when the batch is posted.
- If the Post zero line item payments option in the Remittance Profile Library is set to Never, then the zero payment displays on the ERA Import Posting report with the following message: "Not Posted due to the Remittance Profile Library being set to never post zero line item payments".
The Secondary posting functionality includes a claim status of 2 or 20, which can indicate payment by the secondary payer. The same indicator can also be represented when the secondary payer has denied a service line.
The following 5010-related conditions apply when the
CLP02 = 2 with a payment amount equal to $0.00:
- If the Post zero line item payments option in the Remittance Profile Library is set to Always, then the application follows the transaction detail status of the Reason Code returned in the CAS segment. For example, if OA23 is set to Appeal and Skip Adjustment, the application follows these rules and keeps the balance in the Secondary bucket when the batch is posted.
- If the Post zero line item payments option in the Remittance Profile Library is set to Never, then the zero payment displays on the ERA Import Posting report with the following message: "Not Posted due to the Remittance Profile Library being set to never post zero line item payments".
The Tertiary posting functionality includes a claim status of 3 or 21, which can indicate payment by the tertiary payer. The same indicator can also be represented when the tertiary payer has denied a service line.
The following 5010-related conditions apply when the
CLP02 = 3 with a payment amount equal to $0.00:
- If the Post zero line item payments option in the Remittance Profile Library is set to Always, then the application follows the transaction detail status of the Reason Code returned in the CAS Segment. For example, if OA23 is set to Appeal and Skip Adjustment, the application keeps the balance in the Tertiary bucket when the batch is posted.
- If the Post zero line item payments option in the Remittance Profile Library is set to Never, then the zero payment displays on the ERA Import Posting report with the following message: "Not Posted due to the Remittance Profile Library being set to never post zero line item payments".
Claim Status Codes with 5010
- 23 Claim Status is valid in 4010 and 5010. This status is used more often in 5010. The description of this status is “Not our Claim, Forwarded to Additional Payer". This means that if the insurance could not recognize the Subscriber’s ID but recognizes the other payer’s information from the NM1 segment, then they will forward to the next insurance.
- 25 Claim Status Code is “Predetermination Pricing Only- No Payment”. This is generally used for Dental claims when a claim is submitted to inquire about coverage for a particular charge from the payer.
- 27 Claim Status Code- Reviewed (Not Advised) is no longer returned in 5010.
