HCP

Claim Pricing/Repricing Information

Pos: 241

Max: 1

Detail - Optional

Loop: 2300

Elements: 10

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/repricing methodology Trading partners need to agree on the 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
	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, Pricing Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.	O	R	1/18	Required
	HCP03	782	Monetary Amount Description: Monetary amount Industry: Repriced Saving Amount Alias: Savings amount, Pricing Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.	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 Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.	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 Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.	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 Ambulatory Patient Group Code Alias: Approved APG code, Pricing Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.	O	AN	1/30	Situational
	HCP07	782	Monetary Amount Description: Monetary amount Industry: Repriced Approved Ambulatory Patient Group Amount Alias: Approved APG amount, Pricing Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.	O	R	1/18	Situational
	HCP13	901	Reject Reason Code Description: Code assigned by issuer to identify reason for rejection Alias: Reject reason code Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.	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 Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. All valid standard codes are used.	O	ID	1/2	Situational
	HCP15	1527	Exception Code Description: Code specifying the exception reason for consideration of out-of-network health care services Alias: Exception code Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop. All valid standard codes are used.	O	ID	1/2	Situational

Syntax:

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

Semantics:

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.

Comments:

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

Notes:

1. Used only by repricers as needed. This information is specific to the destination payer reported in the 2010BB loop.
2. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim.

Example:

HCP*03*100*10*RPO12345~

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