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Data Element Name:  Source of Payment Typology III
Format-Length:  A/N - 5 Required For:  AS, ED, IP
Effective Date:  7/1/09 Revision Date:        

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

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element

Code

Description
Version 4050R 2300 NTE01 363 UPI Updated Information
NTE02 352 Source of Payment Typology III
No Electronic Mapping

Paper Form Locator Code Qualifier Description State Reporting Purposes
Institutional - UB-04 N/A N/A SPARCS Specific Data Element SPARCS Requires

Definition:

Source of Payment Typology III is used to identify the third payer expected to pay a portion of the patient's bill, if applicable.

Source of Payment Typology is a hierarchical code list. It provides a range of codes from broad categories to related sub-categories that are more specific. Report the expected payer using the greatest level of detail without sacrificing accuracy of the information.

Specific attention should be given to types of payment using Managed Care Plans (MCPs). MCPs operate multiple products (HMO and PPO). Medicare (federal) and Medicaid (state) fund different HMO programs/products within the Managed Care Plans companies. In order to determine the appropriate funding, the MCP should advise on the state or federal funding to accurately determine the source of payment.

Codes and Values:

  1. Must be a valid code in accordance with the Source of Payment Typology Codes in Appendix P.
  2. If Source of Payment Typology III is not applicable, it must contain zeroes.
  3. If this field is reported, it must be left justified and space-filled right.

    Inpatient Example
    Ex: Patient has Medicaid HMO
            NTE*UPI*17    20ALR012072125080211  0000000000~

    Ex: Dual Eligible Patient
            NTE*UPI*0304  20ALR012072125080211  22   00000~

    Outpatient Example
    Ex: Patient has Family Health Plus
            NTE*UPI*17200120721250802302111 0000000000~

    Ex: Patient has Medicaid HMO
            NTE*UPI*1720012072125080230211  0000000000~

    Ex: Patient's race and ethnicity not reported in NTE section and Patient has Child Health Plus
            NTE*UPI*1720   07212508023023   0000000000~

Edit Applications:

  1. Must be a valid entry, if reported.
  2. Medicaid and Medicare payers must be reported with a minimum of two digits from the typology.
  3. Must be located in appropriate position in the NTE segment.
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