HCP

Claim Pricing/Repricing Information

Pos: 241

Max: 1

Detail - Optional

Loop: 2300

Elements: 15

User Option (Usage): Situational

To specify pricing or repricing information about a health care claim or line item

Element Summary:

	Ref	Id	Element Name	Req	Type	Min/Max	Usage
	HCP01	1473	Pricing Methodology Description: Code specifying pricing methodology at which the claim or line item has been priced or repriced Alias: Pricing Methodology Trading partners need to agree on which codes to use in this element. There do not appear to be standard definitions for the code elements.	C	ID	2/2	Required

	Code	Name
	00	Zero Pricing (Not Covered Under Contract)
	01	Priced as Billed at 100%
	02	Priced at the Standard Fee Schedule
	03	Priced at a Contractual Percentage
	04	Bundled Pricing
	05	Peer Review Pricing
	06	Per Diem Pricing
	07	Flat Rate Pricing
	08	Combination Pricing
	09	Maternity Pricing
	10	Other Pricing
	11	Lower of Cost
	12	Ratio of Cost
	13	Cost Reimbursed
	14	Adjustment Pricing

HCP02	782	Monetary Amount Description: Monetary amount Industry: Repriced Allowed Amount Alias: Allowed Amount	O	R	1/18	Required
HCP03	782	Monetary Amount Description: Monetary amount Industry: Repriced Saving Amount Alias: Savings Amount This data element is required when it is necessary to report Savings Amount on claims which has been priced or repriced.	O	R	1/18	Situational
HCP04	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Repricing Organization Identifier Alias: Repricing Organization ID This data element is required when it is necessary to report Repricing Organization ID on claims which has been priced or repriced.	O	AN	1/30	Situational
HCP05	118	Rate Description: Rate expressed in the standard monetary denomination for the currency specified Industry: Repricing Per Diem or Flat Rate Amount Alias: Pricing Rate This data element is required when it is necessary to report Pricing Rate on claims which has been priced or repriced.	O	R	1/9	Situational
HCP06	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Repriced Approved DRG Code Alias: Approved DRG Code This data element is required when it is necessary to report Approved DRG Code on claims which has been priced or repriced.	O	AN	1/30	Situational
HCP07	782	Monetary Amount Description: Monetary amount Industry: Repriced Approved Amount Alias: Approved DRG Amount This data element is required when it is necessary to report Approved DRG Amount on claims which has been priced or repriced.	O	R	1/18	Situational
HCP08	234	Product/Service ID Description: Identifying number for a product or service Industry: Repriced Approved Revenue Code Alias: Approved Revenue Code This data element is required when it is necessary to report Approved Revenue Code on claims which has been priced or repriced.	O	AN	1/48	Situational
HCP09	235	Product/Service ID Qualifier Description: Code identifying the type/source of the descriptive number used in Product/Service ID (234) Industry: Product or Service ID Qualifier Required when HCP10 exists.	C	ID	2/2	Situational

Code

Name

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Description: HCFA coding scheme to group procedure(s) performed on an outpatient basis for payment to hospital under Medicare; primarily used for ambulatory surgical and other diagnostic departments

This code includes Current Procedural Terminology (CPT) and HCPCS coding.

CODE SOURCE:

130: Health Care Financing Administration Common Procedural Coding System

HCP10

234

Product/Service ID
Description: Identifying number for a product or service
Industry: Repriced Approved HCPCS Code
Alias: Approved Procedure Code
This data element is required when it is necessary to report Approved HCPCS Code on claims which has been priced or repriced.

1/48

Situational

	ExternalCodeList
	Name: 130
	Description: Health Care Financing Administration Common Procedural Coding System

HCP11

355

Unit or Basis for Measurement Code
Description: Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
Required when HCP12 exists.

2/2

Situational

	Code	Name
	DA	Days
	UN	Unit

	HCP12	380	Quantity Description: Numeric value of quantity Industry: Repriced Approved Service Unit Count Alias: Approved Service Units This data element is required when it is necessary to report Approved Service Unit Count on claims which has been priced or repriced.	C	R	1/15	Situational
	HCP13	901	Reject Reason Code Description: Code assigned by issuer to identify reason for rejection Alias: Rejection Message This data element is required when it is necessary to report Rejection Message on claims which has been priced or repriced.	C	ID	2/2	Situational

	Code	Name
	T1	Cannot Identify Provider as TPO (Third Party Organization) Participant
	T2	Cannot Identify Payer as TPO (Third Party Organization) Participant
	T3	Cannot Identify Insured as TPO (Third Party Organization) Participant
	T4	Payer Name or Identifier Missing
	T5	Certification Information Missing
	T6	Claim does not contain enough information for re-pricing

HCP14

1526

Policy Compliance Code
Description: Code specifying policy compliance
Alias: Policy Compliance Code
This data element is required when it is necessary to report Policy Compliance Code on claims which has been priced or repriced.

1/2

Situational

	Code	Name
	1	Procedure Followed (Compliance)
	2	Not Followed - Call Not Made (Non-Compliance Call Not Made)
	3	Not Medically Necessary (Non-Compliance Non-Medically Necessary)
	4	Not Followed Other (Non-Compliance Other)
	5	Emergency Admit to Non-Network Hospital

HCP15

1527

Exception Code
Description: Code specifying the exception reason for consideration of out-of-network health care services
Alias: Exception Reason Code
This data element is required when it is necessary to report Exception Reason Code on claims which have been priced or repriced.

1/2

Situational

	Code	Name
	1	Non-Network Professional Provider in Network Hospital
	2	Emergency Care
	3	Services or Specialist not in Network
	4	Out-of-Service Area
	5	State Mandates
	6	Other

1.	R0113 - At least one of HCP01,HCP13 is required
2.	P0910 - If either HCP09,HCP10 is present, then all are required
3.	P1112 - If either HCP11,HCP12 is present, then all are required

1.	HCP02 is the allowed amount.
2.	HCP03 is the savings amount.
3.	HCP04 is the repricing organization identification number.
4.	HCP05 is the pricing rate associated with per diem or flat rate repricing.
5.	HCP06 is the approved DRG code.
6.	HCP07 is the approved DRG amount.
7.	HCP08 is the approved revenue code.
8.	HCP10 is the approved procedure code.
9.	HCP12 is the approved service units or inpatient days.
10.	HCP13 is the rejection message returned from the third party organization.
11.	HCP15 is the exception reason generated by a third party organization.

1.	HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values.

Notes:

1. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.
2. This segment is used when the sender is required to provide the receiver with pricing or repricing information necessary to process the claim or encounter.

Example:

HCP*03*100*10*RPO12345~