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Data Element Name:  Expected Principal Reimbursement
SPARCS Data Element Number:  21
Record Positions:  144 - 145 Format-Length:  A/N - 2
Effective Date:  1/1/1994 Revision Date:  February 2005

Definition:

The code which identifies the payer expected to pay the major portion of the patient's bill.

The Medicare and Medicaid HMO payer codes were used when the HMO responsible for payment received the reimbursement from one of the respective payers for the patient. If this information was not available from the patient's insurance card or from the admittance interview, the Other HMO payer code was used.

Codes and Values:
  1. Must have been a valid code in accordance with the Expected Reimbursement Codes in Appendix D.
Edit Applications:
  1. Prior to October 1, 1995 edits pertaining to ICD-9-CM codes were validated on the basis of the Ambulatory Surgery Service Date/Discharge Date (Data Elements 6) and the Expected Principal Reimbursement. The edit application reflects the yearly updating of the ICD-9-CM codes. ICD-9-CM updates become effective on October 1 for Medicare, CHAMPUS, and Medicare HMO discharges and on January 1 of the following year for all other payer discharges.

    NOTE: After October 1, 1995, based on the Department of Health Memorandum (Health Facilities Series: H4 95-7) issued on May 1, 1995, all edits pertaining to ICD-9-CM codes are validated on the basis of the Ambulatory Surgery Service Date/Discharge Date (Data Elements 6). The edit application reflects the yearly updating of the ICD-9-CM codes. The ICD-9-CM updates became effective on October 1 for all payers.

  2. This field is not required for Emergency Department records.

Conversion Notes:

  1. There were several hundred records in data years prior to 1994 that had a code of "05". This code could not be supported. All "05" codes were changed to "10" - Other Insurance Company