Change Request Detail
No.
854
Date
1/5/2004
Submitter
Type of Request
Claim Status Request and Response
Status
DSMO Process Completed
Business Reason
There are instances where in a large number of claims may need to be adjusted due to an error in payment.  In these instances, the plan may opt to settle with the provider for a set dollar amount for claims prior to a certain date.  In these instances, when claims are received for a date that the settlement applied, the health plan would deny the claim for "Included in Settlement". 
Suggestion
A claim status that can be used with a description of "Included in claim settlement".
DSMO Category
D
Recommendation
This is not a DSMO issue.  This request looks like it is related to the business of the Claim Payment and not the HIPAA claim status response.  Please review the following web site for more information and a listing of applicable codes: www.wpc-edi.com/adjustmentstatuscodes/form.asp
Appeal Recommendation