Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | AcutePay1 | 8072 | Primary acute payor: | 1989-10-01 - Variable Added |
Form 1 | AcutePay2 | 390 | Secondary acute payor: | 1989-10-01 - Variable Added |
Form 1 | RehabPay1 | 8073 | Primary rehabilitation payor: | 1989-10-01 - Variable Added |
Form 1 | RehabPay2 | 547 | Secondary rehabilitation payor: | 1989-10-01 - Variable Added |
PAYOR SOURCE
Definition
Primary (largest) payor source(s) for both acute and rehabilitation hospitalizations
4 - Private Insurance includes Employee Insurance, Privately Purchased Policies such as BCBS, HMO, PPO, TRICARE/TRIWEST, Federal Exchanges, etc.
8 - State or County includes State Crippled Children, Department Of Rehab, etc.
14 - Charity includes Hospital Provided Free Care
Form
[X] Form 1
[ ] Form 2
Source
Form 1 - Abstraction (acute record, rehab record)
Details
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. If the payor source is not clear, contact your hospital’s billing department to determine correct payor source.
Code ‘55. Payor Source Pending’ should be used only as a place holder until the actual payment source is known.
Payor sources fitting more than 1 category should be coded only once, and are not to be broken-out between the primary and secondary sources. If present, any type of ‘’managed care’’ category should be given the highest prioritization. For example, if the payor source is “Auto Insurance with HMO” code ‘6. HMO.’
Medicaid HMO should be coded ‘2. Medicaid’.
Characteristics
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 re-coding, re-coded these cases to codes 15 through 18 as appropriate.
Several categories were combined / re-defined on 10/1/2011:
01 = Medicare (unable to determine if traditionally or managed care administered) [CHANGED TO 01 = Medicare]
02 = Medicaid (unable to determine if traditionally or managed care administered) [CHANGED TO 02 = Medicaid]
03 = Workers’ Compensation [UNCHANGED]
04 = Blue Cross/Shield [COMBINED WITH 05 = Private Insurance (Other); CHANGED TO 04 = Private Insurance, Other (BC/BS, Employee Insurance, Privately Purchased Policies, Etc.)]
05 = Private Insurance (Other) [COMBINED WITH 04 = Blue Cross/Blue Shield; CODE 05 REMOVED]
06 = HMO (Health Maintenance Organization) [UNCHANGED]
07 = Private Pay [CHANGED TO 07 = Self Or Private Pay]
08 = State Crippled Children’s [COMBINED WITH 09 = Department of Rehabilitation; CHANGED TO 08 = State or County (State Crippled Children, Department of Rehab, Etc.)]
09 = Department of Rehabilitation [COMBINED WITH 08 = State Crippled Children’s; CODE 09 REMOVED]
10 = No Fault Insurance [CHANGED TO 10 = Auto Insurance]
11 = PPO [UNCHANGED]
12 = CHAMPUS [CHANGED TO 12 = TRICARE/TRIWEST (Formerly CHAMPUS)]
14 = Hospital (free bed) [CHANGED TO 14 = Hospital Free Care]
15 = Medicare (traditionally administered) [COMBINED WITH 01 = Medicare (unable to determine if traditionally or managed care administered); CODE 15 REMOVED]
16 = Medicaid (traditionally administered) [COMBINED WITH 02 = Medicaid (unable to determine if traditionally or managed care administered); CODE 16 REMOVED]
17 = Medicare (managed care administered) [COMBINED WITH 01 = Medicare (unable to determine if traditionally or managed care administered); CODE 17 REMOVED]
18 = Medicaid (managed care administered) [COMBINED WITH 02 = Medicaid (unable to determine if traditionally or managed care administered); CODE 18 REMOVED]
19 = DoD (VA database only - not a TBIMS code) [UNCHANGED]
20 = VA (VA database only - not a TBIMS code) [UNCHANGED]
55 = Medicaid Pending [CHANGED TO 55 = Payor Source Pending]
77 = Other [UNCHANGED]
88 = N/A (No care given or no secondary payor) [CHANGED TO 88 = Not Applicable (No Secondary Payor)]
99 = Unknown [UNCHANGED]
In 2017 More categories were combined - the existing variable was copied to the variable archive and the live variable was recoded by combining all private insurance together (4-private insurance: other; 6-HMO; 11-PPO; and 12-TRICARE/TRIWEST). Also recommended to rename “Hospital Free Care” as “Charity.”
In 2018, copied current variable to Archives and re-coded variable to combine all private insurances together and rename Hospital Free care to “Charity”
Variables
Codes and Values
ID | Code | Description |
|---|---|---|
390 | 1 | Medicare |
390 | 2 | Medicaid |
390 | 3 | Workers Compensation |
390 | 4 | Private Insurance ( Employee Insurance, Privately Purchased Policies such as BCBS, HMO, PPO, TRICARE/TRIWEST, Federal Exchanges, etc. ) |
390 | 7 | Self or Private Pay |
390 | 8 | State or County ( State Crippled Children, Department Of Rehab, etc. ) |
390 | 10 | Auto Insurance |
390 | 14 | Charity ( Hospital Provided Free Care ) |
390 | 15 | Other |
390 | 55 | Payor Source Pending |
390 | 888 | Not Applicable: No secondary payor |
390 | 999 | Unknown |
547 | 1 | Medicare |
547 | 2 | Medicaid |
547 | 3 | Workers Compensation |
547 | 4 | Private Insurance ( Employee Insurance, Privately Purchased Policies such as BCBS, HMO, PPO, TRICARE/TRIWEST, Federal Exchanges, etc. ) |
547 | 7 | Self or Private Pay |
547 | 8 | State or County ( State Crippled Children, Department Of Rehab, etc. ) |
547 | 10 | Auto Insurance |
547 | 14 | Charity ( Hospital Provided Free Care ) |
547 | 15 | Other |
547 | 55 | Payor Source Pending |
547 | 888 | Not Applicable: No secondary payor |
547 | 999 | Unknown |
8072 | 1 | Medicare |
8072 | 2 | Medicaid |
8072 | 3 | Workers Compensation |
8072 | 4 | Private Insurance ( Employee Insurance, Privately Purchased Policies such as BCBS, HMO, PPO, TRICARE/TRIWEST, Federal Exchanges, etc. ) |
8072 | 7 | Self or Private Pay |
8072 | 8 | State or County ( State Crippled Children, Department Of Rehab, etc. ) |
8072 | 10 | Auto Insurance |
8072 | 14 | Charity ( Hospital Provided Free Care ) |
8072 | 15 | Other |
8072 | 55 | Payor Source Pending |
8072 | 999 | Unknown |
8073 | 1 | Medicare |
8073 | 2 | Medicaid |
8073 | 3 | Workers Compensation |
8073 | 4 | Private Insurance ( Employee Insurance, Privately Purchased Policies such as BCBS, HMO, PPO, TRICARE/TRIWEST, Federal Exchanges, etc. ) |
8073 | 7 | Self or Private Pay |
8073 | 8 | State or County ( State Crippled Children, Department Of Rehab, etc. ) |
8073 | 10 | Auto Insurance |
8073 | 14 | Charity ( Hospital Provided Free Care ) |
8073 | 15 | Other |
8073 | 55 | Payor Source Pending |
8073 | 999 | Unknown |
History
Date | Description |
|---|---|
1995-01-01 | Deleted CODE : dropped Alternate Level of Care payor source. |
1997-01-01 | Added NOTE : about Medicaid pending cases. |
1999-04-02 | Added CODE : to differentiate between traditional and managed care administered Medicare and Medicaid, added note regarding recoding of old data. |
2004-01-14 | Added NOTE : to contact a person in your hospital's billing department when payor source is in question. |
2008-04-01 | Added CODE : 55 = Medicaid Pending |
2009-10-01 | Added NOTE : code ''55 - Medicaid Pending'' should be used only as a place holder until the payment source is known |
2009-10-01 | Deleted NOTE : if Medicaid status is pending at the time of discharge, code as ''Medicaid'' and change code when pending status is determined. |
2011-10-01 | Changed CODE : several categories were combined/re-classified - see ''Characteristics of Data'' for details. |
2013-04-01 | Added NOTE : Medicaid HMO should be coded "Medicaid". |
2016-07-01 | Removed NOTE: payor source should be verified that it has not changed just prior to the next quarterly submission. |
2017-01-01 | Added CHARACTERISTICS : Copied current variable to Archives and recoded variable to combine all private insurances together and rename Hospital Free care to "Charity" |
2019-10-01 | Removed NOTE: This variable should be collected based on who pays the bill. It should be collected just prior to quarterly submission. |
2023-01-15 | Removed CODE : "888 - Not Applicable: No secondary payor” removed from acute and rehab primary payor source. |