1.3.6.1.4.1.19376.1.5.3.1.4.18

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Trial.gif Payer Entry 1.3.6.1.4.1.19376.1.5.3.1.4.18

The payer entry allows information about the patient's sources of payment to be recorded.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Payer Entry

Specification
Payer Entry Example
<act classCode='ACT' moodCode='EVN'>
  <templateId root='2.16.840.1.113883.10.20.1.26'/>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>
  <id root='' extension=''/>
  <code code='' displayName='' codeSystem='' codeSystemName=''/>
  <statusCode code='completed'/>
  <performer typeCode='PRF'><!-- payer -->
    <assignedEntity classCode='ASSIGNED'>
      <id root='' extension=''/>
      <code code='PAYOR|GUAR|PAT' displayName=''
        codeSystem='2.16.840.1.113883.5.110' codeSystemName='RoleClass'/>
      <addr></addr>
      <telecom value='' use=''/>
      <representedOrganization typeCode='ORG'>
        <name></name>
      </representedOrganization>
    </assignedEntity>
  </performer>
  <participant typeCode='COV'><!-- member -->
    <participantRole classCode='PAT'>
      <id root='' extension=''/>
      <code code='' displayName='' 
        codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>
      <addr></addr>
      <telecom value='' use=''/>
      <playingEntity><name></name></playingEntity>
    </participantRole>
  </participant>
  <participant typeCode='HLD'><!-- subscriber -->
    <participantRole classCode='PAT'>
      <id root='' extension=''/>
      <playingEntity><name></name></playingEntity>
    </participantRole>
  </participant>
  <entryRelationship typeCode='REFR'>
    <act classCode='ACT' moodCode='DEF'>
      <id root='' extension=''/>
      <code code='' displayName='' codeSystem='' codeSystemName=''/>
      <text><reference value=''/></text>
    </act>
  </entryRelationship>
</act>


<act classCode='ACT' moodCode='EVN'>

The policy entry <act> describes the policy or program that has agreed to pay (moodCode='EVN') for the patient's treatment.

<templateId root='2.16.840.1.113883.10.20.1.26'/>
   <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.18'/>

The <act> conforms to CCD: 3.1.2.1.2 and this guide. This shall be reflected by including the <templateId> elements shown above.

<id root=' ' extension=' '/>

The <act> shall contain at least one <id> element that represents the policy or group number of the coverage. That identifier shall appear in the extension attribute.

<code code=' ' displayName=' '
    codeSystem=' ' codeSystemName=' '/>

The <code> element should be present, and represents the type of coverage provided by the payer. Potential vocabularies to use include:

Vocabulary Description OID
HL7 ActCoverageType The HL7 ActCoverageType vocabulary describes payers and programs. Note that HL7 does not have a specific code to identify an individual payer, e.g., in the role of a guarantor or patient. 2.16.840.1.113883.5.4
X12 Data Element 1336 The X12N 271 implementation guide includes various types of payers. This code set does include a code to identify individual payers. 2.16.840.1.113883.6.255.1336
Payer Type Vocabularies
<statusCode code='completed'/>

The <statusCode> element shall be present, and should be recorded exactly as shown above.

<performer typeCode='PRF'>
    <assignedEntity classCode='ASSIGNED'>

The <performer> element shall be present to represent the payer of the coverage.

<id root=' ' extension=' '/>

The identity of the performer should be recorded in the <id> element.

<code code='PAYOR|GUAR|PAT' displayName=' '
      codeSystem='2.16.840.1.113883.5.110'
      codeSystemName='RoleClass'/>

The <code> element describes the role of the payer. It shall contain one of the values listed in the table below.

Payer Role Codes
Code Description
PAYOR Used to indicate that the payer is a payor for a policy or program.
GUAR Used to indicate that the payer is a guarantor for the patient.
PAT Used to indicate that the payer is the patient.
<addr></addr>

The <addr> element shall be used to record the address of the payer. This information will usually come from the back of an insurance card.

<telecom value=' ' use=' '/>

The <telecom> element shall be used to record the phone number of the payer. This information will usually come from the back of an insurance card.

<representedOrganization typeCode='ORG'>
 <name></name>

The name of the payer organization shall be provided in the <name> element contained within the <representedOrganization> element.

<participant typeCode='COV'>
 <participantRole classCode='PAT'>

Information about the patient with respect to the policy or program shall be recorded in the <participantRole> element shown above. This element shall be present when the patient is a member of a policy or program.

<id root=' ' extension=' '/>

The <id> element should contain the identifier of the patient with respect to the payer (the subscriber or member id).

<code code= displayName= codeSystem='2.16.840.1.113883.5.111' codeSystemName='RoleCode'/>

The <code> element shall indicate the covered parties relationship to the subscriber, and should come from the HL7 CoverageRoleType value set.

<addr></addr>

The <addr> element should be used to record the address of the patient as known to the payer when different from that recorded in the <patientRole> element.

<telecom value=' ' use=' '/>

The <telecom> element should be used to record the phone number of the patient when different from that recorded in the <patientRole> element.

<playingEntity><name></name></playingEntity>

The <name> element should be used to record the member name when it is different from that recorded in the <patient> element.

<participant typeCode='HLD'>
 <participantRole classCode='IND'>

Information about subscriber to the policy or program shall be recorded in the <participantRole> element shown above. This element shall be present when the subscriber is different from the patient.

<id root=' ' extension=' '/>

The <id> element shall contain the identifier of the subscriber when the subscriber is not the patient.

<addr></addr>

The <addr> element shall be used to record the address of the subscriber when the subscriber is not the patient.

<telecom value=' ' use=' '/>

The <telecom> element shall be used to record the phone number of the subscriber when the subscriber is not the patient.

<playingEntity><name></name></playingEntity>

The name of the subscriber shall be recorded in the <name> element of the <playingEntity>.

<entryRelationship typeCode='REFR'>
 <act classCode='ACT' moodCode='DEF'>

The plan information may be provided in the elements described above.

<id root=' ' extension=' '/>

The health plan identifier is recorded in the <id> element.

<text><reference value=' '/></text>

This <reference> element shown above should be present and the value attribute should point to the name of the plan contained in the narrative of the document.