Live Syllabus

CODE:

01 = Medicare (unable to determine if traditionally or managed care administered)
02 = Medicaid (unable to determine if traditionally or managed care administered)
03 = Workers' Compensation
04 = Blue Cross/Shield
05 = Private Insurance - Other
06 = HMO (Health Maintenance Organization)
07 = Private Pay
08 = State Crippled Children's
09 = Department of Rehabilitation
10 = No Fault Insurance
11 = PPO
12 = CHAMPUS
14 = Hospital (free bed)
15 = Medicare (traditionally administered)
16 = Medicaid (traditionally administered)
17 = Medicare (managed care administered)
18 = Medicaid (managed care administered)

77 = Other
88 = N/A - no care given or no secondary payor
99 = Unknown

NOTE:

If the payor source is recorded as "Medicaid Pending" at the time of data collection, code as Medicaid, keep track of which cases these are and review cases at the time of follow-up to determine if Medicaid was approved or denied. If Medicaid was denied, determine who paid the bill and code appropriately.

All cases coded as "01 - Medicare" or "02 - Medicaid" prior to 4/2/99 remained in these coding categories. Centers with the ability to perform retrospective recoding, recoded these cases to codes 15 through 18 as appropriate.

This variable should be collected based on who pays the bill. It should be collected just prior to quarterly submission. It should then be verified that it has not changed just prior to the next quarterly submission.

EXAMPLE:

Acute hospitalization - primary, Medicare traditional, secondary, Blue Cross/Shield.
Inpatient Rehabilitation - primary, private insurance, secondary, none.
a. 15 04
b. 04 88

QUESTIONS & ANSWERS:

view all questions & answers

QUESTION: We have a subject that was involved in an airplane crash. The primary source of insurance is actually the commercial insurance from the flight school. (Pan American International Flight Academy). The bills are being sent to Phoenix Aviation Mgr. Inc. What type of payor is this?

ANSWER: Any given payor may have many kinds of policies, so the name of the payor is often not sufficient information for determining type of policy. In order to determine type of policy, contact a person in your hospital's billing department who is familiar with this person's case. (01-14-2004)