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Data Element Name:  Claim Filing Indicator Code / Source of Payment Code
Format-Length:  A/N - 2 Required For:  AS, ED, IP
Effective Date:  1/1/94 Revision Date:  October 2007

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element

Code

Description
Version 4050R 2000B SBR09 1032 Claim Filing Indicator Code

2320 SBR09 1032 Claim Filing Indicator Code

Paper Form Locator Code Qualifier Description
Institutional - UB-04 N/A N/A Not on Paper Format

Definition:

The code which indicates the type of payment. The code listing below was obtained from the ASC X12N 4050 Implementation Guide.

Codes and Values:

CODE DEFINITION
09 Self-pay
11 Other Non-Federal Programs
12 Preferred Provider Organization (PPO)
14 Exclusive Provider Organization (EPO)
15 Indemnity Insurance
16 Health Maintenance Organization (HMO) Medicare Risk
BL Blue Cross/Blue Shield
CH CHAMPUS
CI Commercial Insurance Co.
HM Health Maintenance Organization
MA Medicare Part A
MB Medicare Part B
MC Medicaid
OF Other Federal Program
VA Veterans Affairs Plan
WC Workers' Compensation Health Claim

Edit Applications:

The tables below indicate the additional data items that are required, depending on the value in the Claim Filing Indicator Code and whether the claim is Inpatient or Outpatient.

Ambulatory Surgery and Emergency Department Only:


Claim of Filing Indicator Code

Payer ID

Provider ID
09, WC, OF, CH, VA - -
11, 14, 15, MA, MB, MC - REQUIRED
12, 16, CI, HM REQUIRED -
BL REQUIRED REQUIRED

Inpatient Only:


Claim Filing Indicator
Code

Payer
ID

Policy
Number

Provider
ID
09, WC, OF, CH, VA - - -
11, 14, 15, MA, MB, MC - REQUIRED REQUIRED
12, 16, CI, or HM REQUIRED REQUIRED -
BL REQUIRED REQUIRED REQUIRED

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