Health Care Insurance Payment Type Codes

$79 / 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

John Snow Labs Standard License

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

Name Description Type Constraints
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
WRITEOFFWrite off amountState-Based Markets (SBM) only2014-06-01ActiveSBM Only
MDCAIDState Medicaid Subsidy. RMR04 will be positive.State-Based Markets (SBM) only2013-10-01ActiveSBM Only
OPMUFOPM Multi-State Plan user fee. RMR04 will be negative.State-Based Markets (SBM) only2013-10-01ActiveSBM Only
SMANDState Mandate Benefit Subsidy. RMR04 will be positive.State-Based Markets (SBM) only2013-10-01ActiveSBM Only
SBMUFState Based Marketplace User Fee. RMR04 will be negative.State-Based Markets (SBM) only2015-05-01ActiveSBM Only
COMMAny commissions withheld by the Exchange. RMR04 will be negative.State-Based Markets (SBM) only2013-10-01ActiveSBM Only
COMMADJAny commissions adjustment. RMR04 will be positive or negative.State-Based Markets (SBM) only2013-10-01ActiveSBM Only
DEDUCTDeductible amount due to the Payer. RMR04 will be positive or negative.State-Based Markets (SBM) only2015-10-01ActiveSBM Only
REFUNDTotal refunded amount sent back to the customer. RMR04 will be negative.State-Based Markets (SBM) only2013-10-01ActiveSBM Only
MDCAIDADJState Medicaid Subsidy Adjustment. RMR04 will be positive or negative.State-Based Markets (SBM) only2013-10-01ActiveSBM Only