Statutes, codes, and regulations
California Code Of Regulations
Title 22 - Social SecurityDivision 7 - Health Planning and Facility ConstructionChapter 10 - Health Facility Data
Article 8 - Patient Data Reporting Requirements
Section 97232 - Definition of Data Element for Inpatients-Expected Source of Payment

Cal. Code Regs. tit. 22 § 97232

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Current through Register 2024 Notice Reg. No. 49, December 6, 2024
Section 97232 - Definition of Data Element for Inpatients-Expected Source of Payment

Effective with discharges on or after January 1, 1999, the patient's expected source of payment -- the entity or organization which is expected to pay or did pay the greatest share of the patient's bill -- shall be reported using the following:

(1) Payer Category. Select one of the following:
(A) Medicare. A federally administered third party reimbursement program authorized by Title XVIII of the Social Security Act. Includes crossovers to secondary payers.
(B) Medi-Cal. A state administered third party reimbursement program authorized by Title XIX of the Social Security Act.
(C) Private Coverage. Payment covered by private, non-profit, or commercial health plans, whether insurance or other coverage, or organizations. Included are payments by local or organized charities, such as the Cerebral Palsy Foundation, Easter Seals, March of Dimes, or Shriners.
(D) Workers' Compensation. Payment from workers' compensation insurance, government or privately sponsored.
(E) County Indigent Programs. Patients covered under Welfare and Institutions Code Section 17000. Includes programs funded in whole or in part by County Medical Services Program (CMSP), California Healthcare for Indigents Program (CHIP), and/or Realignment Funds whether or not a bill is rendered.
(F) Other Government. Any form of payment from government agencies, whether local, state, federal, or foreign, except those in Subsections (1)(A), (1)(B), (1)(D), or (1)(E) of this section. Includes funds received through the California Children Services (CCS), the Civilian Health and Medical Program of the Uniformed Services (TRICARE), and the Veterans Administration.
(G) Other Indigent. Patients receiving care pursuant to Hill-Burton obligations or who meet the standards for charity care pursuant to the hospital's established charity care policy. Includes indigent patients, except those described in Subsection (1)(E) of this section.
(H) Self Pay. Payment directly by the patient, personal guarantor, relatives, or friends. The greatest share of the patient's bill is not expected to be paid by any form of insurance or other health plan.
(I) Other Payer. Any third party payment not included in Subsections (1)(A) through (1)(H) of this section. Included are cases where no payment will be required by the facility, such as special research or courtesy patients.
(2) Type of Coverage. For each Payer Category, Subsections (1)(A) through (1)(F) of this section, select one of the following Types of Coverage:
(A) Managed Care -- Knox-Keene/Medi-Cal County Organized Health System. Health care service plans, including Health Maintenance Organizations (HMO), licensed by the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975. Includes Medi-Cal County Organized Health Systems (COHS).
(B) Managed Care -- Other. Health care plans, except those in Subsection (2)(A) of this section, which provide managed care to enrollees through a panel of providers on a pre-negotiated or per diem basis, usually involving utilization review. Includes Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), and Point of Service (POS).
(C) Traditional Coverage. All other forms of health care coverage, including the Medicare prospective payment system, indemnity or fee-for-service plans, or other fee-for-service payers.
(3) Health Plan Identification Number. If Type of Coverage is reported as category (A) above, report the specific plan providing coverage by listing the four digit health plan identification number assigned by the California Department of Managed Health Care (DMHC). If Type of Coverage is reported as category (A) above and if the health plan has a pending Knox-Keene license application with DMHC or if the health plan is a COHS that does not have a DMHC assigned number, the four digit health plan identification number shall be reported as 8000.

Cal. Code Regs. Tit. 22, § 97232

1. New section filed 10-14-93; operative 11-15-93 (Register 93, No. 42).
2. Amendment filed 7-23-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 30).
3. Amendment of section, including new subsection (a)(3)(A), filed 9-21-98; operative 10-21-98 (Register 98, No. 39).
4. Editorial correction of HISTORY 3 (Register 2000, No. 20).
5. Change without regulatory effect repealing subsections (a)-(a)(14), renumbering subsections, amending newly designated subsections (a)(1)(F), (a)(1)(G), (a)(1)(I), (a)(2), (a)(2)(B) and (a)(3)(A), and adopting new subsection (a)(2)(B) filed 5-17-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 20).
6. Change without regulatory effect repealing subsection (a)(3)(A), relettering subsections, amending newly designated subsection (a)(3)(A) and adopting new subsection (a)(3)(B) filed 3-8-2004 pursuant to section 100, title 1, California Code of Regulations (Register 2004, No. 11).
7. Amendment of section heading filed 5-5-2005; operative 5-5-2005 pursuant to Government Code section 11343.4 (Register 2005, No. 18).
8. Change without regulatory effect amending subsection (a)(1)(C), repealing subsection (a)(3)(A), relettering former subsection (a)(3)(B) to new subsection (a)(3)(A) and adopting new subsection (a)(3)(B) filed 8-11-2005 pursuant to section 100, title 1, California Code of Regulations (Register 2005, No. 32).
9. Amendment filed 12-31-2009; operative 12-31-2009 pursuant to Government Code section 11343.4 (Register 2010, No. 1).
10. Change without regulatory effect amending section filed 7-21-2010 pursuant to section 100, title 1, California Code of Regulations (Register 2010, No. 30).
11. Change without regulatory effect amending subsection (3) -- Table 1 filed 8-23-2011 pursuant to section 100, title 1, California Code of Regulations (Register 2011, No. 34).
12. Change without regulatory effect amending subsection (3) -- Table 1 filed 12-28-2011 pursuant to section 100, title 1, California Code of Regulations (Register 2011, No. 52).
13. Change without regulatory effect amending subsection (3) -- Table 1 filed 3-25-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 13).
14. Change without regulatory effect amending first paragraph, subsections (1) and (3) and subsection (3) -- Table 1 filed 9-23-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 39).
15. Change without regulatory effect amending subsection (3) -- Table 1 filed 8-5-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 32).
16. Change without regulatory effect amending subsection (3) and Table 1 filed 4-30-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 18).
17. Change without regulatory effect amending Table 1 in subsection (3) filed 3-17-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 12).
18. Change without regulatory effect amending subsections (1)(F)-(2), (2)(B) and (3) filed 2-8-2018 pursuant to section 100, title 1, California Code of Regulations (Register 2018, No. 6).
19. Editorial correction of subsection (3) -- Table (Register 2018, No. 12).
20. Change without regulatory effect amending subsections (1) and (3) filed 10-31-2018 pursuant to section 100, title 1, California Code of Regulations (Register 2018, No. 44).
21. Change without regulatory effect amending subsections (2)(A) and (3) filed 5-2-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 18).
22. Change without regulatory effect amending subsections (2)(A)-(B) and (3) filed 9-23-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 39).

Note: Authority cited: Section 128810, Health and Safety Code. Reference: Section 128735, Health and Safety Code.

1. New section filed 10-14-93; operative 11-15-93 (Register 93, No. 42).
2. Amendment filed 7-23-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 30).
3. Amendment of section, including new subsection (a)(3)(A), filed 9-21-98; operative 10-21-98 (Register 98, No. 39).
4. Editorial correction of History 3 (Register 2000, No. 20).
5. Change without regulatory effect repealing subsections (a)-(a)(14), renumbering subsections, amending newly designated subsections (a)(1)(F), (a)(1)(G), (a)(1)(I), (a)(2), (a)(2)(B) and (a)(3)(A), and adopting new subsection (a)(2)(B) filed 5-17-2000 pursuant to section 100, title 1, California Code of Regulations (Register 2000, No. 20).
6. Change without regulatory effect repealing subsection (a)(3)(A), relettering subsections, amending newly designated subsection (a)(3)(A) and adopting new subsection (a)(3)(B) filed 3-8-2004 pursuant to section 100, title 1, California Code of Regulations (Register 2004, No. 11).
7. Amendment of section heading filed 5-5-2005; operative 5-5-2005 pursuant to Government Code section 11343.4 (Register 2005, No. 18).
8. Change without regulatory effect amending subsection (a)(1)(C), repealing subsection (a)(3)(A), relettering former subsection (a)(3)(B) to new subsection (a)(3)(A) and adopting new subsection (a)(3)(B) filed 8-11-2005 pursuant to section 100, title 1, California Code of Regulations (Register 2005, No. 32).
9. Amendment filed 12-31-2009; operative 12-31-2009 pursuant to Government Code section 11343.4 (Register 2010, No. 1).
10. Change without regulatory effect amending section filed 7-21-2010 pursuant to section 100, title 1, California Code of Regulations (Register 2010, No. 30).
11. Change without regulatory effect amending subsection (3) - Table 1 filed 8-23-2011 pursuant to section 100, title 1, California Code of Regulations (Register 2011, No. 34).
12. Change without regulatory effect amending subsection (3) - Table 1 filed 12-28-2011 pursuant to section 100, title 1, California Code of Regulations (Register 2011, No. 52).
13. Change without regulatory effect amending subsection (3) - Table 1 filed 3-25-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 13).
14. Change without regulatory effect amending first paragraph, subsections (1) and (3) and subsection (3) - Table 1 filed 9-23-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 39).
15. Change without regulatory effect amending subsection (3) - Table 1 filed 8-5-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 32).
16. Change without regulatory effect amending subsection (3) and Table 1 filed 4-30-2015 pursuant to section 100, title 1, California Code of Regulations (Register 2015, No. 18).
17. Change without regulatory effect amending Table 1 in subsection (3) filed 3-17-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 12).
18. Change without regulatory effect amending subsections (1)(F)-(2), (2)(B) and (3) filed 2-8-2018 pursuant to section 100, title 1, California Code of Regulations (Register 2018, No. 6).
19. Editorial correction of subsection (3) - Table (Register 2018, No. 12).
20. Change without regulatory effect amending subsections (1) and (3) filed 10-31-2018 pursuant to section 100, title 1, California Code of Regulations (Register 2018, No. 44).
21. Change without regulatory effect amending subsections (2)(A) and (3) filed 5-2-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 18).
22. Change without regulatory effect amending subsections (2)(A)-(B) and (3) filed 9-23-2019 pursuant to section 100, title 1, California Code of Regulations (Register 2019, No. 39).