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Data Element Name:  Source of Payment Information Group Definition File Location:  Master, De-Identified
SPARCS Data Element Number:  38 - 45
Record Positions:  214 - 609 Format-Length:  A/N - 66
Effective Date:  1/1/1994 Revision Date:              
Deniable Data Element:   This data element group is composed of both non-deniable and deniable components. See the individual field description to determine its deniability and Appendix Z for release restrictions.

The following block of data represents information about the payers involved in adjudicating the claim for each patient stay. For claims that involve multiple payers, multiple sequences of payer data are submitted.

The maximum number of sequences that could have been reported for payer-related data was six (6).

Data Element
Number
Data Element
Name

Occurrence

Record Positions
38 Source of Payment Code 1 214 - 214
2 280 - 280
3 346 - 346
4 412 - 412
5 478 - 478
6 544 - 544

39 Policy Number 1 215 - 233
2 281 - 299
3 347 - 365
4 413 - 431
5 479 - 497
6 545 - 563

40 Payer Identification 1 234 - 238
2 300 - 304
3 366 - 370
4 432 - 436
5 498 - 502
6 564 - 568

Filler 1 239 - 250
2 305 - 316
3 371 - 382
4 437 - 448
5 503 - 514
6 569 - 580

41 Covered Days 1 251 - 254
2 317 - 320
3 383 - 386
4 449 - 452
5 515 - 518
6 581 - 584

42 Non-Covered Days 1 255 - 258
2 321 - 324
3 387 - 390
4 453 - 456
5 519 - 522
6 585 - 588

43 Provider Identification Number 1 259 - 271
2 325 - 337
3 391 - 403
4 457 - 469
5 523 - 535
6 589 - 601

44 Alternate Level of Care Days 1 272 - 275
2 338 - 341
3 404 - 407
4 470 - 473
5 536 - 539
6 602 - 605

45 Leave of Absence Days 1 276 - 279
2 342 - 345
3 408 - 411
4 474 - 477
5 540 - 543
6 606 - 609

Conversion Notes:

Based on the position of data in the UBF, Source of Payment Code and other appropriate fields were populated with data from the UBF. Since the UBF payer fields were dedicated to specific payers, and the UDS payer fields are not the conversion was complex. The table on the following page indicates the UBF fields that were used to populate the payer group information.

PAYER INFO on UBF
Source of Payment Code
(DE 38)
Insurance Policy Number
(DE 39)
Payer ID
(DE 40)
Covered Days
(DE 41)
Provider ID
(DE 43)
Medicare 'C' if Medicare Claim present Medicare Claim Number 0 Medicare Provider Number
Blue Cross 1 'G' if Blue Cross Certificate ID #1 present Blue Cross Certificate ID #1 Blue Cross Certificate Plan #1 Blue Cross Full Days #1 Blue Cross Provider Number
Blue Cross 2 'G' if Blue Cross Certificate ID #2 present Blue Cross Certificate ID #2 Blue Cross Certificate Plan #1 Blue Cross Full Days #2 Blue Cross Provider Number
Commercial 'B' if Ind = "WC"
'F' if Ind = "NF"
'A' if commer. company is 'SELF'
'F' if company policy present
Commercial Policy Number Commercial Company Number Commercial All Inclusive Days Commercial Federal Tax Number
Medicaid 'D' if Medicaid Recipient ID is present Medicaid Recipient ID Medicaid Full Days Medicaid Provider Number