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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 |
