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Data Element Name:  Expected Principal Reimbursement
Format-Length:  A/N - 2 Required For:  AS, IP
Effective Date:  1/1/94 Revision Date:  January 2008

NOTE: This data element is a SPARCS extension, for mapping guidelines refer to the Inpatient and Outpatient 837 Addenda.
New York State Specific Mapping:

Electronic - 837I
X12 Loop
Ref. Des.
Data Element
Code
Description
Version 4050R 2300 NTE01 363 UPI Updated Information
NTE02 352 Expected Principal Reimbursement
Paper Form Locator Code Qualifier Description State Reporting Purposes
Institutional - UB-04 N/A N/A SPARCS Specific Data Element SPARCS Requires

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 are to be used when the HMO responsible for payment receives the reimbursement from one of the respective payers for the patient. If this information is not available from the patient's insurance card or from the admittance interview, the Other HMO payer code should be used.

Codes and Values:

  1. Must be a valid code in accordance with the Expected Reimbursement Codes in Appendix D.

    Inpatient Example:  NTE*UPI*06100120ALR012072125080~

    Outpatient Example:  NTE*UPI*0620012072125080230~

Edit Applications:

  1. Inpatient Only:
    Prior to October 1, 1995 edits pertaining to ICD-9-CM codes are validated on the basis of the Statement Covers Period - Thru Date/Discharge Date 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 Statement Covers Period - Thru Date/ Discharge Date. The edit application reflects the yearly updating of the ICD-9-CM codes. ICD-9-CM updates become effective on October 1 for all payers.
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