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Data Element Name:  Expected Reimbursement Other 2
Format-Length:  A/N - 2 Required For:  IP
Effective Date:  1/1/94 Revision Date:  September 2003

NOTE: This data element is a SPARCS extension, for mapping guidelines refer to the Inpatient Addendum.

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 Reimbursement Other 2

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 tertiary source of payment which is expected to reimburse some part of the hospital 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.

  2. If this field is not applicable it must contain zeroes.

Example: NTE*UPI*06100120ALR012072125080~

Edit Applications:

  1. Must be a valid entry.
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