Primary Payer at Diagnosis

KCR

Primary Payer (PrimaryPayor)

30220

yes

NAACCR

Primary Payer at DX

630

yes

01

Not insured   

Patient has no insurance and is declared a charity write-off

02 

Not insured, self pay

Patient has no insurance and is declared responsible for charges

10

Insurance, NOS   

Type of insurance is unknown or other than types listed in codes 20, 21, 31, 35, 60-68. Use code 10 for prisoners when no further information is available

20

Managed Care, HMO, PPO

An organized system of prepaid care for a group of enrollees usually within a defined geographic area. Generally formed as one of four types: a group model, an independent physician association (IPA), a network, or a staff model. “Gate-keeper model” is another term for describing this type of insurance.

21 

Private Insurance:  Fee-for-service

An insurance plan that does not have negotiated fee structure with the participating hospital. Type of insurance plan not coded as 20.

31

Medicaid 

State government administered insurance for persons who are uninsured, below the poverty level, or covered under entitlement programs.
Medicaid other than Medicaid described in code 35

35 

Medicaid administered through a Managed Care Plan

Patient is enrolled in Medicaid through a Managed Care program (e.g., HMO or PPO). The managed care plan pays for all incurred costs.

60

Medicare without supplement, Medicare, NOS

Federal government funded insurance generally for persons who are 65 years of age or older, are chronically disabled (social security insurance eligible), or are dialysis patients. Includes Medicare without supplement. Not described in codes 61, 62, or 63.

61 

Medicare with supplement NOS

Patient has Medicare and another type of unspecified insurance to pay costs not covered by Medicare. (See also, codes 63 and 64.). Example: Patient is known to have Medicare with a supplement, but the type of Medicare supplement is unknown.

62

Medicare administered through a Managed Care Plan

Patient is enrolled in Medicare through a Managed Care plan (e.g.,HMO or PPO). The Managed Care plan pays for all incurred costs. Example: Patient has a Medicare managed plan (also known as Medicare C or Medicare Advantage). The Medicare managed care plan takes the place of original Medicare plan and will be listed as the first and usually only insurance as a HMO, PPO, etc. [Humana Medicare Advantage, Anthem Medicare Advantage, etc.]

63

Medicare with private supplement

Patient has Medicare and private insurance to pay costs not covered by Medicare.
Example: Patient has Medicare A (inpatient) and B (outpatient and durable medical equipment) with a private supplement to cover costs outside of Medicare A and B.

Medicare with be listed on the patient’s face sheet as the first insurance with the commercial insurance (Medicare supplement) listed second. If Medicare is listed first with Medicaid listed second, capture under code 64.

64

Medicare with Medicaid eligibility

Federal government Medicare insurance with state-administered Medicaid supplement

65

TRICARE (Formerly CHAMPUS)

Department of Defense program providing supplementary civilian sector hospital and medical services beyond a military treatment facility to military dependents, retirees, and their dependents.
Formerly known as CHAMPUS (Civilian Health and Medical Program of the Uniformed Services).

66  

Military

Military personnel or their dependents who are treated at a military facility

67 

Veterans Affairs 

Veterans treated in Department of Veterans Affairs facilities. Example: patient treated at either VA Louisville, VA Lexington, etc.

68 

Indian/Public Health Service

Patient receives care at an Indian Health Service facility or at another facility and medical costs are reimbursed by the Indian Health Service Patient receives care at a Public Health Service facility or at another facility, and medical costs are reimbursed by the Public Health Service

99

 Insurance status unknown 

Patient’s medical record does not indicate whether or not the patient is insured