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FISS/DDE Provider Online Guide: Chapter I


Claim Status and Location Codes

Purpose

The purpose of the status and location is to route claims through FISS.

  • The status describes the general condition of the claim (i.e., whether paid, denied, returned, etc.)
  • The location specifies where the claim resides within the system

Each status/location code is six digits in length. The status is represented by a single alpha code and the location is a five-digit alpha-numeric code. 

The status code alerts the system whether or not the claim should continue processing. The following chart outlines the most common status codes providers will see.

Status Code Description Disposition
A Accepted claim No processing errors; claim continues to the next processing location.
This status will be seen on the reason code file. In essence, the reason code is inactive when this status is assigned, and the claim will not stop for further processing.
S Suspended claim A manual update will be required before further processing of the claim can continue.
Claims that are assigned the ‘S’ status will not appear on the provider’s remittance advice. Claims that are assigned the ‘S’ status are suspended or pending on the system, and will be identified to the provider on the 201 Pend Report.
P Paid/processed claim The claim has reached final disposition (paid/processed).
Claims that are assigned the ‘P’ status will appear on the provider’s remittance advice.
R Reject claim (nonmedical) The claim has reached final disposition with no reimbursement due to nonmedical errors.
Claims that are assigned the ‘R’ status will appear on both the provider’s remittance advice and the 201 Pend Report.
Providers will need to adjust/resubmit rejected claims.
D Denied claim (medical) The claim has reached its final disposition with no reimbursement due to medical errors.
This status code will only be assigned when the claim has been medically denied in full. Partial medical denials are assigned the 'P' status.
Claims that are assigned the ‘D’ status will appear on both the provider’s remittance advice and the 201 Pend Report.
T Return to provider (RTP) The claim has reached its final disposition with no reimbursement due to billing errors.
Claims that are assigned the ‘T’ status will not appear on the provider’s remittance advice. These claims will be identified to the provider in the 201 Pend Report. Providers will need to manually correct/update claims placed in this status.

The location code instructs the system to forward the claim to a specific site before any further claim activity occurs. This five-digit code is comprised of three components.

The first position identifies the type of processing occurring on the claim. Valid values for this first position of the location are:

Code Description
M Manual processing: This is assigned when the claim requires “in-house” processing (i.e., suspended claims).
O Offline processing: This is assigned when the claim detail has been moved to an archived state.
B Batch processing: This is assigned when the claim goes through FISS nightly batch processing cycles.

Positions two and three of the location represent the driver, or bucket, in which the claim is currently residing.   

Valid values for this first position of the location are:  

Code Description Code Description
01 Status/Location 55 Utilization
02 Control 60 ADR
04 UB04 data 63 HHPS Pricer
05 Consistency (I) 65 PPS/Pricer
06 Consistency (II) 70 Payment
15 Administrative 75 Post Payment
25 Duplicate 80 MSP Primary
30 Entitlement 85 MSP Secondary
35 Lab/HCPCS 90 CWF
40 ESRD 95 Denial
50 Medical Policy 99 Session Term

Positions four and five allow for more definition within the driver for the location. Valid values for this first position of the location are:

Code Description Code Description
00 Batch Process 19 Sys Research
01 Common 21 Waiver
02 Adj Orbit 65 Non DDE Pacemaker
10 Inpatient 66 DDE Pacemaker
11 Outpatient 67 DDE Home Health
12 Special Claims 96 Payment Floor
13 Med Review 97 Final Online
14 Program Review 98 Final Offline
16 MSP 99 Final Purged
18 Prod OC    

The chart below identifies the most common status/location codes, which are of greatest significance to providers.  

Status Location Definition
P B 9996 Claim in Omnibus Budget Reconciliation Act (OBRA) hold (i.e., waiting the payment floor hold)
P B 9997 Paid claim (finalized location)
P O 9998 Paid claim (offline)
R B 9997 Rejected claim (finalized location)
D B 9997 Denied claim (finalized location)
T B 9900 Daily return to provider (RTP) location
T B 9997 RTP claim (finalized location)
S B 0100 Beginning of the system (all claims start here)
S B 2500 Claim has been updated by the provider online (awaiting duplicate check)
S B 6000 Claim waiting for ADR to be generated
S B 6001 Claim waiting for response from provider (ADR has already been created)
S B 6098 Claim in an ambulance attachment online location
S B 6099 Claim in a therapy attachment online location
S B 9000 Claim waiting to go to CWF (has cleared all FISS edits)
S B 9099 Awaiting response from CWF
FISS/DDE Provider Online Guide: Chapter I - Claim Status and Location Codes
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