Health Care Insurance Payment Type Codes

$179 / year

Healthcare Insurance Payment Type Codes are transmitted in 005010X306, loop 2300, RMR02. They identify the type and purpose of the health insurance for the payment amount transmitted. This dataset also contains information on the different payment type codes and their descriptions, use of the codes, and the start and modified dates for each code.

Complexity

Healthcare Insurance Payment Type Codes are transmitted in 005010X306, loop 2300, RMR02. They identify the type and purpose for the payment amount transmitted in ASC X12 005010X306, loop 2300, RMR04. The pertinent ASC X12 documentation is available in ASC X12 Stores.
While state-based markets (SBM) may use any code, CMS will only use those codes designated as CMS in the notes below. Issuers in SBM states will need to work with their SBM to determine which codes are applicable to their HIX 820 business process.

The Centers for Medicare & Medicaid Services (CMS) maintain and annually update a List of Current Procedural Terminology (CPT) / Healthcare Common Procedure Coding System (HCPCS) Codes (Code List), which identifies all the items and services included within certain DHS categories. CMS updates the Code List to conform the list to the most recent publications of CPT and HCPCS and to account for changes in Medicare coverage and payment policies. The updated Code List is published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. That rule is usually published in November and generally becomes effective January 1 of the following year. In addition, we may publish other rules or correction notices that may change the Code List. CMS posts any changes to the Code List on its webpage as soon as possible after publication in the Federal Register.

The DHS categories defined by the Code List are:
– Clinical laboratory services;
– Physical therapy services, occupational therapy services, outpatient speech-language pathology services;
– Radiology and certain other imaging services; and
– Radiation therapy services and supplies.

**NOTE**: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:
– Durable medical equipment and supplies;
– Parenteral and enteral nutrients, equipment and supplies;
– Prosthetics, orthotics, and prosthetic devices and supplies;
– Home health services;
– Outpatient prescription drugs; and
– Inpatient and outpatient hospital services.

Date Created

2013-10-01

Last Modified

2017-05-01

Version

2017-05-01

Update Frequency

Irregular

Temporal Coverage

2013 to 2017

Spatial Coverage

United States

Source

John Snow Labs; Centers for Medicare and Medicaid Services and State-Based Markets (SBM);

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Payment Type Codes, Exchange Payment Type codes, Health Insurance Exchange Code Lists, ASC X12 documentation, Code Checker, Health Insurance, Insurance Code, Insurance Electronic Transactions

Other Titles

Health Insurance Portability and Accountability Act (HIPAA) Standard Electronic Transactions, Medicare Appropriate Exchange Payment Type codes, Health Insurance Exchange Payment Type Code Lists, Payment Type Codes for State-Based Markets (SBM), CMS Payment Type Codes, CMS Exchange Payment Type Codes, ACH Insurance Payment Type Codes, Payment Type Code Checker, Payment Type Sort Codes Sort

NameDescriptionTypeConstraints
CodePayment Type Codesstringunique : 1 required : 1
DescriptionDescription for each Payment Type Codesstringunique : 1 required : 1
TypeDescription of the appropriate use of the Payment Type Codestringrequired : 1
Start_DateDate the Payment Type Code started usagedaterequired : 1
Last_ModifiedDate the Payment Type Code was changed/modifieddate-
Stop_DateDate the Payment Type Code was deactivated/stoppeddate-
StatusCode update whether Active, To be Deactivated or Deactivatedstringrequired : 1
NotesExplanation of the coverage for each Payment Type Codestringrequired : 1
CodeDescriptionTypeStart DateLast ModifiedStop DateStatusNotes
ADMAdministrative Fees used for a debt owed by the payee. This is a program-level code only and no enrollment group (policy) level information will be provided with this code. The Administrative Fee is $15. Negative Amounts OnlyCenters of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2015-11-012017-05-01ActiveCMS All Programs and Relevant Markets
APTCAdvance Payment of Premium Tax Credit. RMR04 will be positive.Centers of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2013-10-012015-11-01ActiveCMS Individual Market Only
APTCADJAdvance Payment of Premium Tax Credit Adjustment. RMR04 will be positive or negative.Centers of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2013-10-012015-11-01ActiveCMS Individual Market Only
APTCMADJAPTC Manual Adjustment. Used to show APTC manual adjustment when enrollment group level information is not applicable. RMR04 will be positive or negative and may be reversed in the future. This is a program-level code only and no enrollment group (policy) level information will be provided with this code.Centers of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2013-10-012015-11-01ActiveCMS Individual Market Only
BALWhen an AR invoice is split between multiple HIX 820 reports, this adjustment balances the reports. Negative Amounts & Positive AmountsCenters of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2013-10-012017-05-01ActiveCMS All Programs and Relevant Markets
CSRAdvance Payment of Cost Sharing Reduction. RMR04 will be positive.Centers of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2013-10-012015-11-01ActiveCMS Individual Market Only
CSRADJAdvance Payment of Cost Sharing Reduction Adjustment. RMR04 will be positive or negative.Centers of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2013-10-012015-11-01ActiveCMS Individual Market Only
CSRMADJCSR Manual Adjustment. Used to show CSR manual adjustment when enrollment group level information is not provided. RMR04 will be positive or negative and may be reversed in the future. This is a program-level code only and no enrollment group (policy) level information will be provided with this code.Centers of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2013-10-012015-11-01ActiveCMS Individual Market Only
CSRNCost Sharing Reduction Reconciliation. Negative Amounts & Positive AmountsCenters of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2015-01-012017-05-01ActiveCMS Exchange Markets
CSRNADJCost Sharing Reduction Reconciliation Adjustment. RMR04 will be positive or negative.Centers of Medicare and Medicaid Services (CMS) or State-Based Markets (SBM)2015-01-012015-11-01ActiveCMS Individual Market Only