Cal. Code Regs. Tit. 22, § 97265 - Definition of Data Element for ED and AS-Expected Source of Payment

The patient's expected source of payment, defined as the type of entity or organization which is expected to pay or did pay the greatest share of the patient's bill, shall be reported using the following categories:

(a) Self-pay. Payment directly by the patient, guarantor, relatives or friends. The greatest share of the patient's bill is not expected to be paid by any form of insurance or other third party.

(b) Other Non-Federal Programs. Include any form of payment from local, county, or state government agencies. Include payments from county funds, whether from county general funds or from other funds used to support county health programs. Include County Indigent Programs, County Medical Services Program (CMSP), California Healthcare for Indigent Program (CHIP), County Children's Health Initiative Program (C-CHIP), and Short-Doyle funds. Also include the State Children's Health Insurance Program (SCHIP), Managed Risk Medical Insurance Board (MRMIB), Healthy Families Program (HFP), and Access for Infants and Mothers (AIM).

(c) Preferred Provider Organization (PPO).

(d) Point of Service (POS).

(e) Exclusive Provider Organization (EPO).

(f) Health Maintenance Organization (HMO) Medicare Risk. Medicare is defined by Title XVIII of the Social Security Act (42 USC 1395 et seq.) and Title I of the Federal Medicare Act (PL 89-97). Include Medicare patients covered under an HMO arrangement.

(g) Automobile Medical. Include PPO, POS, EPO, HMO and Fee for Service or any other payment resulting from automobile coverage.

(h) Blue Cross/Blue Shield. Include only Fee for Service payments. Report PPO, POS, EPO, and HMO under the appropriate stated categories.

(i) CHAMPUS (TRICARE). Include any PPO, POS, EPO, HMO, Fee for Service, or other payment from the Civilian Health and Medical Program of the Uniformed Services or from TRICARE.

(j) Commercial Insurance Company. Report payment from insurance carriers on a Fee for Service basis. Exclude PPO, POS, and EPO, payments.

(k) Disability.

(l) Health Maintenance Organization (HMO). Report HMO payors. Include Knox-Keene licensed plans as well as out of State HMO plans. No Plan Code Number or Plan Code Name is required for ED or AS records. Report Medicare payments covered under an HMO arrangement as Health Maintenance Organization (HMO) Medicare Risk. Report Medi-Cal payments covered under an HMO arrangement as Medicaid.

(m) Medicare Part A. Defined by Title XVIII of the Social Security Act. Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

(n) Medicare Part B. Defined by Title XVIII of the Social Security Act. Covers some outpatient hospital care and some home health services.

(o) Medicaid. Medicaid is called Medi-Cal in California. Defined by Title XIX of the Social Security Act and Title I of the Federal Medicare Act (PL 89-97). Report all Medi-Cal including Fee for Service, PPO, POS, EPO, and HMO.

(p) Other Federal Program. Report federal programs not covered by any other category.

(q) Title V. Defined by the Federal Medicare Act (PL 89-97) for Maternal and Child Health. Title V of the Social Security Act is administered by the Health Resources and Services Administration, Public Health Service, Department of Health and Human Services. Include a Maternal and Child Health program payment that is not covered under Medicaid (Medi-Cal). California Children Services (CCS) payments should be reported here.

(r) Veterans Affairs Plan. Include any PPO, POS, EPO, HMO, Fee for Service, or other payment resulting from Veterans Administration coverage.

(s) Workers' Compensation Health Claim. Payment from Workers' Compensation Health Claim insurance should be reported under this category.

(t) Other. Include payment by governments of other countries. Include payment by local or organized charities, such as the Cerebral Palsy Foundation, Easter Seals, March of Dimes, Shriners, etc. Include payments not listed in other categories.

Notes

Cal. Code Regs. Tit. 22, § 97265

1. New section filed 5-5-2005; operative 5-5-2005 pursuant to Government Code section 11343.4 (Register 2005, No. 18).

Note: Authority cited: Section 128810, Health and Safety Code. Reference: Sections 128736 and 128737, Health and Safety Code.

1. New section filed 5-5-2005; operative 5-5-2005 pursuant to Government Code section 11343.4 (Register 2005, No. 18).