N.H. Code Admin. R. Ins 4010.06
(a) Insurance Type/Product Code – Eligibility File
Table 4010.06 (a) Insurance Type/Product Code-Eligibility File
Code
Description
12
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13
Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer’s Group Health Plan
14
Medicare Secondary, No-Fault Insurance including Insurance in which Auto Is Primary
15
Medicare Secondary Workers' Compensation
16
Medicare Secondary Public Health Service (PHS) or Other Federal Agency
17
Dental
18
Vision
19
Prescription Drugs
41
Medicare Secondary Black Lung
42
Medicare Secondary Veterans' Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
AP
Auto Insurance Policy
C1
Commercial
CO
Consolidated Omnibus Reconciliation Act (COBRA)
CP
Medicare Conditionally Primary
D
Disability
DB
Disability Benefits
E
Medicare – Point of Service (POS)
EP
Exclusive Provider Organization
FI
Federal Employees Health Benefits Program
FF
Family or Friends
HM
Health Maintenance Organization (HMO)
HN
Health Maintenance Organization (HMO) Medicare Advantage/Risk
HS
Special Low Income Medicare Beneficiary
IN
Indemnity
IP
Individual Policy
LC
Long Term Care
LD
Long Term Policy
LI
Life Insurance
LT
Litigation
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
MD
Medicare Part D
MH
Medigap Part A
MI
Medigap Part B
MP
Medicare Primary
OT
Other
PE
Property Insurance – Personal
PR
Preferred Provider Organization (PPO)
PS
Point of Service (POS)
QM
Qualified Medicare Beneficiary
RP
Property Insurance – Real
SP
Supplemental Policy
TF
Tax Equity Fiscal Responsibility Act (TEFRA)
TR
Tricare
U
Multiple Options Health Plan
VA
Veterans Administration Plan
WU
Wrap Up Policy
(b) Relationship Codes
Table 4010.06 (b) Relationship Codes
Code
Description
01
Spouse
02
Son or daughter
03
Father or Mother
04
Grandfather or Grandmother
05
Grandson or Granddaughter
06
Uncle or Aunt
07
Nephew or Niece
08
Cousin
09
Adopted Child
10
Foster Child
11
Son-in-Law or Daughter-in-Law
12
Brother-in-Law or Sister-in-Law
13
Mother-in-Law or Sister-in-Law
14
Brother or Sister
15
Ward
16
Stepparent
17
Stepson or Stepdaughter
18
Self
19
Child
20
Employee/Self
21
Unknown
22
Handicapped Dependent
23
Sponsored Dependent
24
Dependent of a Minor Dependent
25
Ex-spouse
26
Guardian
27
Student
28
Friend
29
Significant Other
30
Both Parents
31
Court Appointed Guardian
32
Mother
33
Father
34
Other Adult
36
Emancipated Minor
37
Agency Representative
38
Collateral Dependent
39
Organ Donor
40
Cadaver Donor
41
Injured Plaintiff
43
Child Where Insured Has No Financial Responsibility
53
Life Partner
76
Dependent
(c) Race 1/Race 2
Table 4010.06 (c) Race 1/Race 2
Code
Description
R1
American Indian/Alaska Native
R2
Asian
R3
Black/African American
R4
Native Hawaiian or Other Pacific Islander
R5
White
R9
Other Race
UNKOW
Unknown/Not Specified
(d) Ethnicity 1/ Ethnicity 2
Table 4010.06 (d) Ethnicity 1/Ethnicity 2
Code
Description
2182-4
Cuban
2184-0
Dominican
2148-5
Mexican, Mexican American, Chicano
2180-8
Puerto Rican
2161-8
Salvadoran
2155-0
Central American (not otherwise specified)
2165-9
South American (not otherwise specified)
2060-2
African
2058-6
African American
AMERCN
American
2028-9
Asian
2029-7
Asian Indian
BRAZIL
Brazilian
2033-9
Cambodian
CVERDN
Cape Verdean
CARIBI
Caribbean Island
2034-7
Chinese
2169-1
Columbian
2108-9
European
2036-2
Filipino
2157-6
Guatemalan
2071-9
Haitian
2158-4
Honduran
2039-6
Japanese
2040-4
Korean
2041-2
Laotian
2118-8
Middle Eastern
PORTUG
Portuguese
RUSSIA
Russian
EASTEU
Eastern European
2047-9
Vietnamese
OTHER
Other Ethnicity
UNKNOW
Unknown/Not Specified
(e) Insurance Type/Product Code – Claims Files
Table 4010.06 (e) Insurance Type/Product Code – Claims Files
Code
Description
11
Other Non-Federal Programs
12
Preferred Provider Organization (PPO)
13
Point of Service (POS)
14
Exclusive Provider Organization (EPO)
15
Indemnity Insurance
16
Health Maintenance Organization (HMO) Medicare Advantage/Risk
17
Dental Maintenance Organization
AM
Automobile Medical
CH
Champus
DS
Disability
FI
Federal Employees Health Benefits Program
HM
Health Maintenance Organization
LI
Liability
LM
Liability Medical
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
MD
Medicare Part D
OF
Other Federal Program (e.g., Black Lung)
SP
Supplemental Policy
TR
Tricare
TV
Title V
VA
Veterans Administration Plan
WC
Workers’ Comp
ZZ
Mutually Defined (Use code ZZ when Type of Insurance is Unknown)
(f) Discharge Status
Table 4010.06 (f) Discharge Status
Code
Description
01
Discharged to home or self-care
02
Discharged/transferred to another short term general hospital for inpatient care
03
Discharged/transferred to skilled nursing facility (SNF)
04
Discharged/transferred to a facility that provides custodial or supportive care
05
Discharged/transferred to a designated cancer center of children’s hospital
06
Discharged/transferred to home under care of organized home health service organization
07
Left against medical advice or discontinued care
08
Reserved for assignment by the NUBC
09
Admitted as an inpatient to this hospital
20
Expired
21
Discharged/transferred to court/law enforcement
30
Still patient or expected to return for outpatient services
40
Expired at home
41
Expired in a medical facility
42
Expired, place unknown
43
Discharged/ transferred to a Federal Hospital
50
Hospice – home
51
Hospice – medical facility
61
Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed
62
Discharged/transferred to an inpatient rehabilitation facility including distinct parts of a hospital
63
Discharged/transferred to a long-term care hospital
64
Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare
65
Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital
66
Discharged/transferred to a critical access hospital (CAH)
69
Discharged/transferred to a designated disaster alternative care site (effective 10/1/13)
70
Discharged/transferred to another type of healthcare institution not defined elsewhere in this code list
81
Discharged to home or self-care with a planned acute care hospital inpatient readmission (effective 10/1/13)
82
Discharged/transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission (effective 10/1/13)
83
Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission (effective 10/1/13)
84
Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission (effective 10/1/13)
85
Discharged/transferred to designated cancer center of children’s hospital with a planned acute care hospital inpatient readmission (effective 10/1/13)
86
Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission (effective 10/1/13)
87
Discharged/transferred to court / law enforcement with a planned acute care hospital inpatient readmission (effective 10/1/13)
88
Discharged/transferred to a federal healthcare facility with a planned acute care hospital inpatient readmission (effective 10/1/13)
89
Discharged/transferred to a hospital‐based Medicare approved swing bed with a planned acute care hospital inpatient readmission (effective 10/1/13)
90
Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission (effective 10/1/13)
91
Discharged/transferred to a Medicare certified long term care hospital (LTCH) with a planned acute care hospital inpatient readmission (effective 10/1/13)
92
Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission (effective 10/1/13)
93
Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital with a planned acute care hospital inpatient readmission (effective 10/1/13)
94
Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission (effective 10/1/13)
95
Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission (effective 10/1/13)
(g) Place of Service – Professional
Table 4010.06 (g) Place of Service -- Professional
Code
Description
01
Pharmacy
02
Unassigned
03
School
04
Homeless Shelter
05
Indian Health Service Free-Standing Facility
06
Indian Health Service Provider-Based Facility
07
Tribal 638 Free-Standing Facility
08
Tribal 638 Provider-Based Facility
09
Prison/Correctional Facility
10
Unassigned
11
Office
12
Home
13
Assisted Living Facility Congregate
14
Group Home
15
Mobile Unit
16
Temporary Lodging
17
Walk-in Retail Health Clinic
18
Place of Employment-Worksite
19
Unassigned
20
Urgent Care Facility
21
Inpatient Hospital
22
Outpatient Hospital
23
Emergency Room – Hospital
24
Ambulatory Surgery Center
25
Birthing Center
26
Military Treatment Facility
27-30
Unassigned
31
Skilled Nursing Facility
32
Nursing Facility
33
Custodial Care Facility
34
Hospice
35-40
Unassigned
41
Ambulance – Land
42
Ambulance – Air or Water
43-48
Unassigned
50
Federally Qualified Center
51
Inpatient Psychiatric Facility
52
Psychiatric Facility Partial Hospitalization
53
Community Mental Health Center
54
Intermediate Care Facility/Mentally Retarded
55
Residential Substance Abuse Treatment Facility
56
Psychiatric Residential Treatment Center
57
Non-Residential Substance Abuse Treatment Facility
58-59
Unassigned
60
Mass Immunization Center
61
Comprehensive Inpatient Rehabilitation Facility
62
Comprehensive Outpatient Rehabilitation Facility
63-64
Unassigned
65
End Stage Renal Disease Treatment Facility
66-70
Unassigned
71
State or Local Public Health Clinic
72
Rural Health Clinic
73-80
Unassigned
81
Independent Laboratory
82-98
Unassigned
99
Other Unlisted Facility
(h) Claim Status
Table 4010.06 (h) Claim Status
Code
Description
01
Processed as primary
02
Processed as secondary
03
Processed as tertiary
04
Denied
06
Approved as amended
19
Processed as primary, forwarded to additional payer(s)
21
Processed as tertiary, forwarded to additional payer(s)
22
Reversal of previous payment
26
Documentation Claim - No Payment Associated
28
Repriced
(i) MC021 Point of Origin Codes
(1) If MC020 = 4 (Newborn), then use the following values at MC021:
Table 4010.06 (i) (1) MC021 Point of Origin Codes
Code
Description
5
Born Inside the Hospital
6
Born Outside the Hospital
(2) For all other values at MC020, use the following table for MC021:
Table 4010.06 (i) (2) Point of Origin Codes
Code
Description
1
Non-Healthcare Facility Point of Origin (Physician Referral)
2
Clinic Referral
3
HMO Referral
4
Transfer from a Hospital (Different Facility)
5
Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)
6
Transfer from Another Health Care Facility
7
Emergency Room
8
Court/Law Enforcement
9
Information Not Available
A
Reserved for National Assignment
B
Transfer from Another Home Health Agency(Discontinued July 1,2010)
C
Readmission to Same Home Health Agency (Discontinued July 1,2010)
D
Transfer from Hospital Inpatient in the Same Facility Resulting in a Separate Claim to the Payer
E
Transfer from Ambulatory Surgical Center
F
Transfer from Hospice and is Under a Hospice Plan of Care or Enrolled in Hospice Program
Source. #10877, eff 7-10-15; ss by #13136, eff 11-24-20