PCS Product Claim Status

To convey the status of a product service claim or claims or to supply adjustment reason codes and amounts as needed for an entire claim or for a particular item within the claim

Position: PCS-01 · Element: 1029 · Name: Claim Status Code · Type: Identifier (ID) · Requirement: Conditional · Min: 1 · Max: 2 · Repeat: -

Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization

R0104: At least one of PCS-01 or PCS-04 is required

PCS01 will be used principally when the entire claim has been approved and no more detail is required or when there is a question about the claim that has to be decided and the claim response is to inform the claimant that the claim is pending and has not been forgotten.

Position: PCS-02 · Element: 559 · Name: Agency Qualifier Code · Type: Identifier (ID) · Requirement: Conditional · Min: 2 · Max: 2 · Repeat: -

Code identifying the agency assigning the code values

C0204: If PCS-02 is present, then PCS-04 is required

PCS02 identifies the source of the code.

Position: PCS-03 · Element: 822 · Name: Source Subqualifier · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 15 · Repeat: -

A reference that indicates the table or text maintained by the Source Qualifier

C0302: If PCS-03 is present, then PCS-02 is required

PCS03 specifies a particular table of codes maintained by the agency identified in PCS02.

Position: PCS-04 · Element: 1172 · Name: Claim Response Reason Code · Type: Identifier (ID) · Requirement: Conditional · Min: 1 · Max: 3 · Repeat: -

Code identifying the detailed reason for the response

PCS04 identifies the status of the claim or an individual portion of the claim and the reason for any change in the claimed amount.

Position: PCS-05 · Element: 782 · Name: Monetary Amount · Type: Decimal number (R) · Requirement: Optional · Min: 1 · Max: 15 · Repeat: -

Monetary amount

PCS05 is the value to be paid after the application of any claim adjustment.

Position: PCS-06 · Element: 889 · Name: Follow-up Action Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code identifying follow-up actions allowed

PCS06 provides instructions to the claim submitter as to the next action to be taken when the claim was not approved as submitted.

Position: PCS-07 · Element: 559 · Name: Agency Qualifier Code · Type: Identifier (ID) · Requirement: Conditional · Min: 2 · Max: 2 · Repeat: -

Code identifying the agency assigning the code values

C0709: If PCS-07 is present, then PCS-09 is required

Position: PCS-08 · Element: 822 · Name: Source Subqualifier · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 15 · Repeat: -

A reference that indicates the table or text maintained by the Source Qualifier

C0807: If PCS-08 is present, then PCS-07 is required

PCS08 is the source of the code in PCS09. It is a particular table of codes maintained by the organization specified in PCS07 for specifying PCS09.

Position: PCS-09 · Element: 1225 · Name: Disposition Code · Type: String (AN) · Requirement: Conditional · Min: 3 · Max: 3 · Repeat: -

Code specifying the disposition of removed part, subassembly, or assembly

PCS09 is the disposition of the part of subassembly.

Position: PCS-10 · Element: 352 · Name: Description · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 80 · Repeat: -

A free-form description to clarify the related data elements and their content

PCS10 describes why a claim amount was changed when such information cannot be conveyed with a code value.

Position: PCS-11 · Element: 553 · Name: Authorization Identification · Type: String (AN) · Requirement: Optional · Min: 1 · Max: 4 · Repeat: -

Identifier representing authorization of an unusual repair or some attendant condition

PCS11 can apply to an authorization before a repair action took place.