Code

Label

Definition

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 unknown or other than the types listed in codes 20, 21, 31, 35, 60–68.

20

PRIVATE INSURANCE:  MANAGED CARE, HMO, OR 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 a negotiated fee structure with the participating reporting facility. Type of insurance plan not coded as 20.

28

HMO

California specific code

29

PPO

California specific code

31

MEDICAID

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

Medicaid other than described in code 35.

35

MEDICAID ADMINISTERED THROUGH A MANAGED CARE PLAN

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

60

MEDICARE WITHOUT SUPPLEMENT, MEDICARE, NOS

Federal government funded insurance for persons who are 62 years of age or older, or are chronically disabled (Social Security insurance eligible). 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.

62

MEDICARE - ADMINISTERED THROUGH A MANAGED CARE PLAN

Patient is enrolled in Medicare through a Managed Care plan (for example, HMO or PPO). The Managed Care plan pays for all incurred costs

63

MEDICARE WITH PRIVATE SUPPLEMENT

Patient has Medicare and private insurance to pay costs not covered by Medicare.

64

MEDICARE WITH MEDICAID ELIGIBILITY

Federal government Medicare insurance with State Medicaid administered supplement.

65

TRICARE

Department of Defense program providing supplementary civilian-sector reporting facility and medical services beyond a military treatment facility to military dependents, retirees, and their dependents.

Formally 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 who are treated in Veterans Affairs facilities.

68

INDIAN/PUBLIC HEALTH SERVICES

Patient who receives care at an Indian Health Service facility or at another facility, and the 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.

89

COUNTY FUNDED, NOS

California specific code

99

INSURANCE STATUS UNKNOWN

It is unknown from the patient’s medical record whether or not the patient is insured.