Source of Payment Typology Update: A New National Standard

Importance of Source of Payment Data Source of payment data used for wide variety public health research and activities Critical need for policymakers and researcher examining effects of payment policy to compare across databases Standardized source of payment data needed to monitor healthcare trends such as access to healthcare and treatment patterns across payer categories

Additional Typology Components Differentiation for Medicaid and Medicare managed care versus non-managed care Ability to distinguish among different types of plans within major payer programs: –Medicare Advantage Plans Ability to separate out self-pay from other reasons of nonpayment: charity care, professional courtesy, and bad debt

Source of Payment Hierarchy Major payer categories allows payer classification at a general level of detail assigned first place value of the code set 2nd level sub-classification for major categories allows more specificity for source of payment classification assigned second place value of code set Additional sub-classification for major categories allows classification at highest level of granularity assigned third, fourth, fifth, and six place value of the code set

GEORGIA: THE PATH SETTER Georgia implemented the PHDSC Payer Typology during the state’s migration from the UB-92 to the UB-04 in 2007 to address the issue of poor data quality in the reporting of payer type information. Hospitals were required to use the Payer Typology starting in 2006 Typology allowed for the flexibility needed to include Medicaid Managed Care plans as well as individual Care Management Organizations local codes within the design of the hierarchical structure.

Georgia (continued) The majority of Georgia hospitals report using the 2-digit level of granularity of the Payer Typology hierarchy followed by a large number of hospitals that report at 3- digit levels of granularity. Only a small number report payer information using the 4 level of granularity.

New Payer Codes Allow Flexibility In 2006, Georgia Medicaid transitioned 1 million enrollees into Medicaid Managed Care plans Set up a payer code to track individual Care Management Organizations 2111AmeriGroup 2112PeachState (Centene) 2113WellCare

New York—Transition to Typology by End of 2009 Added three new payer data element to SPARCS in 2009 called the “Source of Payment Typology (I, II, III)” and replacing the existing data elements that were derived by Department of Health in 1983 called “Expected Principal Reimbursement”. Hospitals required to implement new codes by December 31, 2009

Oregon: Pilot Testing Typology Oregon began pilot testing results from its migration to UB-04 system in June 2008 which included adoption of the 2-digit level of granularity of the PHDSC Payer Typology. Oregon reports that adoption of the new coding has gone well.

CALIFORNIA: CONSIDERING IT California’s direction is to move away from state- specific discharge data reporting systems to nationally supported data reporting standards as it migrates to the national ANSI 837 supported Health Care Service Data Reporting Guide (HCSDRG). This priority includes consideration of the PHDSC Payer Typology as an acceptable nationally supported source of payment code list.

Relationship to National Standards The Data Maintenance to reference the Source of Payment Typology in the ANSI X12 standards within the 837 transaction has been approved. It is anticipated that the October 2007 (5050) and beyond versions of the ANSI X12 standards will provide support for the reporting of the Source of Payment Typology.

Relationship to National Standards Current versions of 837 implementation guides could support reporting of the Payer Typology in the K3 segment with approval of the ANSI X12N Health Claims Work Group (TG2 WG2)

Maintenance Activities The Source of Payment Typology is maintained as an external code list. The existing code list for reporting the Payer Type is an internal ANSI ASC X12 code list.

Maintenance Activities (continued) As an external code list changes made to the Source of Payment Typology do not have to be approved by the ANSI ASC X12 organization. Once changes are made by the Public Health Data Standards Consortium, any new or deprecated codes will be incorporated into any ANSI X12 implementation that now references the Source of Payment Typology without any additional approvals.

Outreach Presentation of poster at NAHDO annual meeting in October ListServe announcements of conference calls of workgroup

Next Steps? Use evaluation with state adopters Educational outreach –Use of Payer Typology poster at conferences