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Data Element Name:  Value Information - Surplus, Catastrophic, or Recurring Monthly Income Code and Amount
Format-Length:  A/N - 2, N - 9 Required For:  IP
Effective Date:  1/1/94 Revision Date:  September 2003

NOTE: This is a composite data element. Up to 12 Value Codes and Amounts can be reported. For mapping guidelines refer to the Inpatient 837 Addendum.

National Standard Mapping:

Electronic - 837I

X12 Loop

Ref. Des.

Data Element

Code

Description
Version 4050R 2300 HI01-1 1270 BE Value Code Qualifier
HI01-2 1271 Value Code
HI01-5 782 Value Code Associated Amount

Paper Form Locator Code Qualifier
Institutional - UB-04 39-41 N/A

Definition:

The monthly payment required of Medicaid patients towards the cost of their hospitalization.

Codes and Values:

  1. 21 = Catastrophic

    22 = Surplus

    23 = Recurring Monthly Income

  2. The Value Amount must be entered in dollars and cents.

    Example:  $125.24 would be entered as: 125.24
Edit Applications:
  1. Must be a valid entry.
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