California Code of Regulations › Title 22 - Social Security › Division 7 - Health Planning and Facility Construction › Chapter 10 - Health Facility Data › Article 8 - Patient Data Reporting Requirements › Section 97265 - Definition of Data Element for ED and AS-Expected Source of Payment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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.
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.