|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
100A |
TANF < 1 M & F WITH MEDICARE PPC |
10/96 |
|
|
100B |
TANF 01-05 M & F WITH MEDICARE PPC |
10/96 |
|
|
100C |
TANF 06-13 M & F WITH MEDICARE PPC |
10/96 |
|
|
100D |
TANF 14-20 MALE WITH MEDICARE PPC |
10/96 |
|
|
100E |
TANF 14-20 FEMALE WITH MEDICARE PPC |
10/96 |
|
|
100F |
TANF 21-44 MALE WITH MEDICARE PPC |
10/96 |
|
|
100G |
TANF 21-44 FEMALE WITH MEDICARE PPC |
10/96 |
|
|
100H |
TANF 44-64 M & F WITH MEDICARE PPC |
10/96 |
|
|
100J |
TANF 65+ M & F WITH MEDICARE PPC |
10/96 |
|
|
100Z |
TANF ALTCS WITH MEDICARE PPC |
10/96 |
|
|
1000 |
TANF WITH MEDICARE |
10/82 |
|
|
1001 |
TANF < 1 M & F WITH MEDICARE |
10/97 |
|
|
1002 |
TANF 01-05 M & F WITH MEDICARE |
10/97 |
|
|
1003 |
TANF 06-13 M & F WITH MEDICARE |
10/97 |
|
|
1004 |
TANF 14-20 MALE WITH MEDICARE |
10/97 |
|
|
1005 |
TANF 14-20 FEMALE WITH MEDICARE |
10/97 |
|
|
1006 |
TANF 21-44 MALE WITH MEDICARE |
10/97 |
|
|
1007 |
TANF 21-44 FEMALE WITH MEDICARE |
10/97 |
|
|
1008 |
TANF 45-64 M & F WITH MEDICARE |
10/97 |
|
|
1009 |
TANF 65+ M & F WITH MEDICARE |
10/97 |
|
|
101A |
TANF < 1 M & F NON-MEDICARE PPC |
10/96 |
|
|
101B |
TANF 01-05 M & F NON-MEDICARE PPC |
10/96 |
|
|
101C |
TANF 06-13 M & F NON-MEDICARE PPC |
10/96 |
|
|
101D |
TANF 14-20 MALE NON-MEDICARE PPC |
10/96 |
|
|
101E |
TANF 14-20 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
101F |
TANF 21-44 MALE NON-MEDICARE PPC |
10/96 |
|
|
101G |
TANF 21-44 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
101H |
TANF 44-64 M & F NON-MEDICARE PPC |
10/96 |
|
|
101J |
TANF 65+ N & F NON-MEDICARE PPC |
10/96 |
|
|
101Z |
TANF ALTCS NON-MEDICARE PPC |
10/96 |
|
|
1010 |
TANF NON-MEDICARE |
10/82 |
|
|
1011 |
TANF <1 M & F NON-MEDICARE |
10/97 |
|
|
1012 |
TANF 01-05 M & F NON-MEDICARE |
10/97 |
|
|
1013 |
TANF 06-13 M & F NON-MEDICARE |
10/97 |
|
|
1014 |
TANF 14-20 MALE NON-MEDICARE |
10/97 |
|
|
1015 |
TANF 14-20 FEMALE NON-MEDICARE |
10/97 |
|
|
1016 |
TANF 21-44 MALE NON-MEDICARE |
10/97 |
|
|
1017 |
TANF 21-44 FEMALE NON-MEDICARE |
10/97 |
|
|
1018 |
TANF 45-64 M & F NON-MEDICARE |
10/97 |
|
|
1019 |
TANF 65+ M & F NON-MEDICARE |
10/97 |
|
|
102A |
TANF < 1 M & F WITH QMB PPC |
10/96 |
|
|
102B |
TANF 01-05 M & F WITH QMB PPC |
10/96 |
|
|
102C |
TANF 06-13 M & F WITH QMB PPC |
10/96 |
|
|
102D |
TANF 14-20 MALE WITH QMB PPC |
10/96 |
|
|
102E |
TANF 14-20 FEMALE WITH QMB PPC |
10/96 |
|
|
102F |
TANF 21-44 MALE WITH QMB PPC |
10/96 |
|
|
102G |
TANF 21-44 FEMALE WITH QMB PPC |
10/96 |
|
|
102H |
TANF 44-64 M & F WITH QMB PPC |
10/96 |
|
|
102J |
TANF 65+ M & F WITH QMB PPC |
10/96 |
|
|
102Z |
TANF ALTCS WITH QMB PPC |
10/96 |
|
|
1020 |
TANF WITH QMB |
01/89 |
|
|
1021 |
TANF <1 M & F WITH QMB |
10/97 |
|
|
1022 |
TANF 01-05 M & F WITH QMB |
10/97 |
|
|
1023 |
TANF 06-13 M & F WITH QMB |
10/97 |
|
|
1024 |
TANF 14-20 MALE WITH QMB |
10/97 |
|
|
1025 |
TANF 14-20 FEMALE WITH QMB |
10/97 |
|
|
1026 |
TANF 21-44 MALE WITH QMB |
10/97 |
|
|
1027 |
TANF 21-44 FEMALE WITH QMB |
10/97 |
|
|
1028 |
TANF 45-64 M & F WITH QMB |
10/97 |
|
|
1029 |
TANF 65+ M & F WITH QMB |
10/97 |
|
|
110A |
TANF EXPANDED <1 M & F W/MDC PPC |
04/01 |
|
|
110B |
TANF EXPANDED 01-05 M & F W/MDC PPC |
04/01 |
|
|
110C |
TANF EXPANDED 06-13 M & F W/MDC PPC |
04/01 |
|
|
110D |
TANF EXPANDED 14-20 MALE W/MDC PPC |
04/01 |
|
|
110E |
TANF EXPANDED 14-20 FEMALE W/MDC PPC |
04/01 |
|
|
110F |
TANF EXPANDED 21-44 MALE W/MDC PPC |
04/01 |
|
|
110G |
TANF EXPANDED 21-44 FEMALE W/MDC PPC |
04/01 |
|
|
110H |
TANF EXPANDED 45-64 M & F W/MDC PPC |
04/01 |
|
|
110J |
TANF EXPANDED 65+ M & F W/MDC |
04/01 |
|
|
1101 |
TANF EXPANDED <1 M & F W/MDC |
04/01 |
|
|
1102 |
TANF EXPANDED 01-05 M & F W/MDC |
04/01 |
|
|
1103 |
TANF EXPANDED 06-13 M & F W/MDC |
04/01 |
|
|
1104 |
TANF EXPANDED 14-20 MALE W/MDC |
04/01 |
|
|
1105 |
TANF EXPANDED 14-20 FEMALE W/MDC |
04/01 |
|
|
1106 |
TANF EXPANDED 21-44 MALE W/MDC |
04/01 |
|
|
1107 |
TANF EXPANDED 21-44 FEMALE W/MDC |
04/01 |
|
|
1108 |
TANF EXPANDED 45-64 M & F W/MDC |
04/01 |
|
|
1109 |
TANF EXPANDED 65+ M & F W/MDC |
04/01 |
|
|
111A |
TANF EXPANDED <1 M & F NO MDC PPC |
04/01 |
|
|
111B |
TANF EXPANDED 01-05 M & F NO MDC PPC |
04/01 |
|
|
111C |
TANF EXPANDED 06-13 M & F NO MDC PPC |
04/01 |
|
|
111D |
TANF EXPANDED 14-20 MALE NO MDC PPC |
04/01 |
|
|
111E |
TANF EXPANDED 14-20 FEMALE NO MDC PPC |
04/01 |
|
|
111F |
TANF EXPANDED 21-44 MALE NO MDC PPC |
04/01 |
|
|
111G |
TANF EXPANDED 21-44 FEMALE NO MDC PPC |
04/01 |
|
|
111H |
TANF EXPANDED 45-64 M & F NO MDC PPC |
04/01 |
|
|
111J |
TANF EXPANDED 65+ M & F NO MDC PPC |
04/01 |
|
|
1111 |
TANF EXPANDED <1 M & F NO MDC |
04/01 |
|
|
1112 |
TANF EXPANDED 01-05 M & F NO MDC |
04/01 |
|
|
1113 |
TANF EXPANDED 06-13 M & F NO MDC |
04/01 |
|
|
1114 |
TANF EXPANDED 14-20 MALE NO MDC |
04/01 |
|
|
1115 |
TANF EXPANDED 14-20 FEMALE NO MDC |
04/01 |
|
|
1116 |
TANF EXPANDED 21-44 MALE NO MDC |
04/01 |
|
|
1117 |
TANF EXPANDED 21-44 FEMALE NO MDC |
04/01 |
|
|
1118 |
TANF EXPANDED 45-64 M & F NO MDC |
04/01 |
|
|
1119 |
TANF EXPANDED 65+ M & F NO MDC |
04/01 |
|
|
112A |
TANF EXPANDED <1 M & F W/QMB PPC |
04/01 |
|
|
112B |
TANF EXPANDED 01-05 M & F W/QMB PPC |
04/01 |
|
|
112C |
TANF EXPANDED 06-13 M & F W/QMB PPC |
04/01 |
|
|
112D |
TANF EXPANDED 14-20 MALE W/QMB PPC |
04/01 |
|
|
112E |
TANF EXPANDED 14-20 FEMALE W/QMB PPC |
04/01 |
|
|
112F |
TANF EXPANDED 21-44 MALE W/QMB PPC |
04/01 |
|
|
112G |
TANF EXPANDED 21-44 FEMALE W/QMB PPC |
04/01 |
|
|
112H |
TANF EXPANDED 45-64 M & F W/QMB PPC |
04/01 |
|
|
112J |
TANF EXPANDED 65+ M & F W/QMB PPC |
04/01 |
|
|
1121 |
TANF EXPANDED <1 M & F W/QMB |
04/01 |
|
|
1122 |
TANF EXPANDED 01-05 M & F W/QMB |
04/01 |
|
|
1123 |
TANF EXPANDED 06-13 M & F W/QMB |
04/01 |
|
|
1124 |
TANF EXPANDED 14-20 MALE W/QMB |
04/01 |
|
|
1125 |
TANF EXPANDED 14-20 FEMALE W/QMB |
04/01 |
|
|
1126 |
TANF EXPANDED 21-44 MALE W/QMB |
04/01 |
|
|
1127 |
TANF EXPANDED 21-44 FEMALE W/QMB |
04/01 |
|
|
1128 |
TANF EXPANDED 45-64 M & F W/QMB |
04/01 |
|
|
1129 |
TANF EXPANDED 65+ M & F W/QMB |
04/01 |
|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
210Z |
SSI AGED WITH MEDICARE PPC |
10/96 |
|
|
2100 |
SSI AGED WITH MEDICARE |
10/82 |
|
|
211Z |
SSI AGED NON-MEDICARE PPC |
10/96 |
|
|
2110 |
SSI AGED NON-MEDICARE |
10/82 |
|
|
212Z |
SSI AGED WITH QMB PPC |
10/96 |
|
|
2120 |
SSI AGED WITH QMB |
01/89 |
|
|
220Z |
SSI DISABLED WITH MEDICARE PPC |
10/96 |
|
|
2200 |
SSI DISABLED WITH MEDICARE |
10/82 |
|
|
221Z |
SSI DISABLED NON-MEDICARE PPC |
10/96 |
|
|
2210 |
SSI DISABLED NON-MEDICARE |
10/82 |
|
|
222Z |
SSI DISABLED WITH QMB PPC |
10/96 |
|
|
2220 |
SSI DISABLED WITH QMB |
01/89 |
|
|
230Z |
SSI BLIND WITH MEDICARE PPC |
10/96 |
|
|
2300 |
SSI BLIND WITH MEDICARE |
10/82 |
|
|
231Z |
SSI BLIND NON-MEDICARE PPC |
10/96 |
|
|
2310 |
SSI BLIND NON-MEDICARE |
10/82 |
|
|
232Z |
SSI BLIND WITH QMB PPC |
10/96 |
|
|
2320 |
SSI BLIND WITH QMB |
01/89 |
|
|
240Z |
SSI AGED EXPANDED WITH MEDICARE PPC |
04/01 |
|
|
2400 |
SSI AGED EXPANDED WITH MEDICARE |
04/01 |
|
|
241Z |
SSI AGED EXPANDED NO MDC PPC |
04/01 |
|
|
2410 |
SSI AGED EXPANDED NO MDC |
04/01 |
|
|
242Z |
SSI AGED EXPANDED WITH QMB PPC |
04/01 |
|
|
2420 |
SSI AGED EXPANDED WITH QMB |
04/01 |
|
|
250Z |
SSI BLIND EXPANDED WITH MEDICARE PPC |
04/01 |
|
|
2500 |
SSI BLIND EXPANDED WITH MEDICARE |
04/01 |
|
|
251Z |
SSI BLIND EXPANDED NO MDC PPC |
04/01 |
|
|
2510 |
SSI BLIND EXPANDED NO MDC |
04/01 |
|
|
252Z |
SSI BLIND EXPANDED WITH QMB PPC |
04/01 |
|
|
2520 |
SSI BLIND EXPANDED WITH QMB |
04/01 |
|
|
260Z |
SSI DISABLED EXPANDED WITH MDC PPC |
04/01 |
|
|
2600 |
SSI DISABLED EXPANDED WITH MDC |
04/01 |
|
|
261Z |
SSI DISABLED EXPANDED NON-MDC PPC |
04/01 |
|
|
2610 |
SSI DISABLED EXPANDED NON-MDC |
04/01 |
|
|
262Z |
SSI DISABLED EXPANDED WITH QMB PPC |
04/01 |
|
|
2620 |
SSI DISABLED EXPANDED WITH QMB |
04/01 |
|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
300Z |
MN/MI WITH MEDICARE PPC |
10/96 |
|
|
3000 |
MN/MI WITH MEDICARE |
10/82 |
|
|
301Z |
MN/MI NON-MEDICARE PPC |
10/96 |
|
|
3010 |
MN/MI NON-MEDICARE |
10/82 |
|
|
330A |
AHC CARE M & F <1 W/MDC PPC |
10/01 |
|
|
330B |
AHC CARE M & F 01-05 W/MDC PPC |
10/01 |
|
|
330C |
AHC CARE M & F 06-13 W/MDC PPC |
10/01 |
|
|
330D |
AHC CARE MALE 14-20 W/MDC PPC |
10/01 |
|
|
330E |
AHC CARE FEMALE 14-20 W/MDC PPC |
10/01 |
|
|
330F |
AHC CARE MALE 21-44 W/MDC PPC |
10/01 |
|
|
330G |
AHC CARE FEMALE 21-44 W/MDC PPC |
10/01 |
|
|
330H |
AHC CARE M & F 45-64 W/MDC PPC |
10/01 |
|
|
330J |
AHC CARE M & F 65+ W/MDC PPC |
10/01 |
|
|
3301 |
AHC CARE M & F <1 W/MDC |
10/01 |
|
|
3302 |
AHC CARE M & F 01-05 W/MDC |
10/01 |
|
|
3303 |
AHC CARE M & F 06-13 W/MDC |
10/01 |
|
|
3304 |
AHC CARE MALE 14-20 W/MDC |
10/01 |
|
|
3305 |
AHC CARE FEMALE 14-20 W/MDC |
10/01 |
|
|
3306 |
AHC CARE MALE 21-44 W/MDC |
10/01 |
|
|
3307 |
AHC CARE FEMALE 21-44 W/MDC |
10/01 |
|
|
3308 |
AHC CARE M & F 45-64 W/MDC |
10/01 |
|
|
3309 |
AHC CARE M & F 65+ W/MDC |
10/01 |
|
|
331A |
AHC CARE M & F <1 NO-MED PPC |
10/01 |
|
|
331B |
AHC CARE M & F 01-05 NO-MED PPC |
10/01 |
|
|
331C |
AHC CARE M & F 06-13 NO-MED PPC |
10/01 |
|
|
331D |
AHC CARE MALE 14-20 NO-MED PPC |
10/01 |
|
|
331E |
AHC CARE FEMALE 14-20 NO-MED PPC |
10/01 |
|
|
331F |
AHC CARE MALE 21-44 NO-MED PPC |
10/01 |
|
|
331G |
AHC CARE FEMALE 21-44 NO-MED PPC |
10/01 |
|
|
331H |
AHC CARE M & F 45-64 NO-MED PPC |
10/01 |
|
|
331J |
AHC CARE M & F 65+ NO-MED PPC |
10/01 |
|
|
3311 |
AHC CARE M & F <1 NO-MED |
10/01 |
|
|
3312 |
AHC CARE M & F 01-05 NO-MED |
10/01 |
|
|
3313 |
AHC CARE M & F 06-13 NO-MED |
10/01 |
|
|
3314 |
AHC CARE MALE 14-20 NO-MED |
10/01 |
|
|
3315 |
AHC CARE FEMALE 14-20 NO-MED |
10/01 |
|
|
3316 |
AHC CARE MALE 21-44 NO-MED |
10/01 |
|
|
3317 |
AHC CARE FEMALE 21-44 NO-MED |
10/01 |
|
|
3318 |
AHC CARE M & F 45-64 NO-MED |
10/01 |
|
|
3319 |
AHC CARE M & F 65+ NO-MED |
10/01 |
|
|
332A |
AHC CARE M & F <1 W/QMB PPC |
10/01 |
|
|
332B |
AHC CARE M & F 01-05 W/QMB PPC |
10/01 |
|
|
332C |
AHC CARE M & F 06-13 W/QMB PPC |
10/01 |
|
|
332D |
AHC CARE MALE 14-20 W/QMB PPC |
10/01 |
|
|
332E |
AHC CARE FEMALE 14-20 W/QMB PPC |
10/01 |
|
|
332F |
AHC CARE MALE 21-44 W/QMB PPC |
10/01 |
|
|
332G |
AHC CARE FEMALE 21-44 W/QMB PPC |
10/01 |
|
|
332H |
AHC CARE M & F 45-64 W/QMB PPC |
10/01 |
|
|
332J |
AHC CARE M & F 65+ W/QMB PPC |
10/01 |
|
|
3321 |
AHC CARE M & F <1 W/QMB |
10/01 |
|
|
3322 |
AHC CARE M & F 01-05 W/QMB |
10/01 |
|
|
3323 |
AHC CARE M & F 06-13 W/QMB |
10/01 |
|
|
3324 |
AHC CARE MALE 14-20 W/QMB |
10/01 |
|
|
3325 |
AHC CARE FEMALE 14-20 W/QMB |
10/01 |
|
|
3326 |
AHC CARE MALE 21-44 W/QMB |
10/01 |
|
|
3327 |
AHC CARE FEMALE 21-44 W/QMB |
10/01 |
|
|
3328 |
AHC CARE M & F 45-64 W/QMB |
10/01 |
|
|
3329 |
AHC CARE M & F 65+ W/QMB |
10/01 |
|
|
340Z |
MED ELIGIBILITY W/MDC PPC |
04/01 |
|
|
3400 |
MED ELIGIBILITY W/MDC |
04/01 |
|
|
341Z |
MED ELIGIBILITY NON-MDC PPC |
04/01 |
|
|
3410 |
MED ELIGIBILITY NON-MDC |
04/01 |
|
|
342Z |
MED ELIGIBILITY W/QMB PPC |
04/01 |
|
|
3420 |
MED ELIGIBILITY W/QMB |
04/01 |
|
|
350A |
AHC CARE HOSP M & F <1 W/MDC PPC |
10/01 |
|
|
350B |
AHC CARE HOSP M & F 01-05 W/MDC PPC |
10/01 |
|
|
350C |
AHC CARE HOSP M & F 06-13 W/MDC PPC |
10/01 |
|
|
350D |
AHC CARE HOSP MALE 14-20 W/MDC PPC |
10/01 |
|
|
350E |
AHC CARE HOSP FEMALE 14-20 W/MDC PPC |
10/01 |
|
|
350F |
AHC CARE HOSP MALE 21-44 W/MDC PPC |
10/01 |
|
|
350G |
AHC CARE HOSP FEMALE 21-44 W/MDC PPC |
10/01 |
|
|
350H |
AHC CARE HOSP M & F 45-64 W/MDC PPC |
10/01 |
|
|
350J |
AHC CARE HOSP M & F 65+ W/MDC PPC |
10/01 |
|
|
3501 |
AHC CARE HOSP M & F <1 W/MDC |
10/01 |
|
|
3502 |
AHC CARE HOSP M & F 01-05 W/MDC |
10/01 |
|
|
3503 |
AHC CARE HOSP M & F 06-13 W/MDC |
10/01 |
|
|
3504 |
AHC CARE HOSP MALE 14-20 W/MDC |
10/01 |
|
|
3505 |
AHC CARE HOSP FEMALE 14-20 W/MDC |
10/01 |
|
|
3506 |
AHC CARE HOSP MALE 21-44 W/MDC |
10/01 |
|
|
3507 |
AHC CARE HOSP FEMALE 21-44 W/MDC |
10/01 |
|
|
3508 |
AHC CARE HOSP M & F 45-64 W/MDC |
10/01 |
|
|
3509 |
AHC CARE HOSP M & F 65+ W/MDC |
10/01 |
|
|
351A |
AHC CARE HOSP M & F <1 NO-MED PPC |
10/01 |
|
|
351B |
AHC CARE HOSP M & F 01-05 NO-MED PPC |
10/01 |
|
|
351C |
AHC CARE HOSP M & F 06-13 NO-MED PPC |
10/01 |
|
|
351D |
AHC CARE HOSP MALE 14-20 NO-MED PPC |
10/01 |
|
|
351E |
AHC CARE HOSP FEMALE 14-20 NO-MED PPC |
10/01 |
|
|
351F |
AHC CARE HOSP MALE 21-44 NO-MED PPC |
10/01 |
|
|
351G |
AHC CARE HOSP FEMALE 21-44 NO-MED PPC |
10/01 |
|
|
351H |
AHC CARE HOSP M & F 45-64 NO-MED PPC |
10/01 |
|
|
351J |
AHC CARE HOSP M & F 65+ NO-MED PPC |
10/01 |
|
|
3511 |
AHC CARE HOSP M & F <1 NO-MED |
10/01 |
|
|
3512 |
AHC CARE HOSP M & F 01-05 NO-MED |
10/01 |
|
|
3513 |
AHC CARE HOSP M & F 06-13 NO-MED |
10/01 |
|
|
3514 |
AHC CARE HOSP MALE 14-20 NO-MED |
10/01 |
|
|
3515 |
AHC CARE HOSP FEMALE 14-20 NO-MED |
10/01 |
|
|
3516 |
AHC CARE HOSP MALE 21-44 NO-MED |
10/01 |
|
|
3517 |
AHC CARE HOSP FEMALE 21-44 NO-MED |
10/01 |
|
|
3518 |
AHC CARE HOSP M & F 45-64 NO-MED |
10/01 |
|
|
3519 |
AHC CARE HOSP M & F 65+ NO-MED |
10/01 |
|
|
352A |
AHC CARE HOSP M & F <1 W/QMB PPC |
10/01 |
|
|
352A |
AHC CARE HOSP M & F 01-05 W/QMB PPC |
10/01 |
|
|
352C |
AHC CARE HOSP M & F 06-13 W/QMB PPC |
10/01 |
|
|
352D |
AHC CARE HOSP MALE 14-20 W/QMB PPC |
10/01 |
|
|
352E |
AHC CARE HOSP FEMALE 14-20 W/QMB PPC |
10/01 |
|
|
352F |
AHC CARE HOSP MALE 21-44 W/QMB PPC |
10/01 |
|
|
352G |
AHC CARE HOSP FEMALE 21-44 W/QMB PPC |
10/01 |
|
|
352H |
AHC CARE HOSP M & F 45-64 W/QMB PPC |
10/01 |
|
|
352J |
AHC CARE HOSP M & F 65+ W/QMB PPC |
10/01 |
|
|
3521 |
AHC CARE HOSP M & F <1 W/QMB |
10/01 |
|
|
3522 |
AHC CARE HOSP M & F 01-05 W/QMB |
10/01 |
|
|
3523 |
AHC CARE HOSP M & F 06-13 W/QMB |
10/01 |
|
|
3524 |
AHC CARE HOSP MALE 14-20 W/QMB |
10/01 |
|
|
3525 |
AHC CARE HOSP FEMALE 14-20 W/QMB |
10/01 |
|
|
3526 |
AHC CARE HOSP MALE 21-44 W/QMB |
10/01 |
|
|
3527 |
AHC CARE HOSP FEMALE 21-44 W/QMB |
10/01 |
|
|
3528 |
AHC CARE HOSP M & F 45-64 W/QMB |
10/01 |
|
|
3529 |
AHC CARE HOSP M & F 65+ W/QMB |
10/01 |
|
|
360A |
AHC CARE/MI M & F <1 W/MDC PPC |
04/01 |
|
|
360B |
AHC CARE/MI M & F 01-05 W/MDC PPC |
04/01 |
|
|
360C |
AHC CARE/MI M & F 06-13 W/MDC PPC |
04/01 |
|
|
360D |
AHC CARE/MI MALE 14-20 W/MDC PPC |
04/01 |
|
|
360E |
AHC CARE/MI FEMALE 14-20 W/MDC PPC |
04/01 |
|
|
360F |
AHC CARE/MI MALE 21-44 W/MDC PPC |
04/01 |
|
|
360G |
AHC CARE/MI FEMALE 21-44 W/MDC PPC |
04/01 |
|
|
360H |
AHC CARE/MI M & F 45-64 W/MDC PPC |
04/01 |
|
|
360J |
AHC CARE/MI M & F 65+ W/MDC PPC |
04/01 |
|
|
3601 |
AHC CARE/MI M & F <1 W/MDC |
04/01 |
|
|
3602 |
AHC CARE/MI M & F 01-05 W/MDC |
04/01 |
|
|
3603 |
AHC CARE/MI M & F 06-13 W/MDC |
04/01 |
|
|
3604 |
AHC CARE/MI MALE 14-20 W/MDC |
04/01 |
|
|
3605 |
AHC CARE/MI FEMALE 14-20 W/MDC |
04/01 |
|
|
3606 |
AHC CARE/MI MALE 21-44 W/MDC |
04/01 |
|
|
3607 |
AHC CARE/MI FEMALE 21-44 W/MDC |
04/01 |
|
|
3608 |
AHC CARE/MI M & F 45-64 W/MDC |
04/01 |
|
|
3609 |
AHC CARE/MI M & F 65+ W/MDC |
04/01 |
|
|
361A |
AHC CARE/MI M & F <1 NO-MED PPC |
04/01 |
|
|
361B |
AHC CARE/MI M & F 01-05 NO-MED PPC |
04/01 |
|
|
361C |
AHC CARE/MI M & F 06-13 NO-MED PPC |
04/01 |
|
|
361D |
AHC CARE/MI MALE 14-20 NO-MED PPC |
04/01 |
|
|
361E |
AHC CARE/MI FEMALE 14-20 NO-MED PPC |
04/01 |
|
|
361F |
AHC CARE/MI MALE 21-44 NO-MED PPC |
04/01 |
|
|
361G |
AHC CARE/MI FEMALE 21-44 NO-MED PPC |
04/01 |
|
|
361H |
AHC CARE/MI M & F 45-64 NO-MED PPC |
04/01 |
|
|
361J |
AHC CARE/MI M & F 65+ NO-MED PPC |
04/01 |
|
|
3611 |
AHC CARE/MI M & F <1 NO-MED |
04/01 |
|
|
3612 |
AHC CARE/MI M & F 01-05 NO-MED |
04/01 |
|
|
3613 |
AHC CARE/MI M & F 06-13 NO-MED |
04/01 |
|
|
3614 |
AHC CARE/MI MALE 14-20 NO-MED |
04/01 |
|
|
3615 |
AHC CARE/MI FEMALE 14-20 NO-MED |
04/01 |
|
|
3616 |
AHC CARE/MI MALE 21-44 NO-MED |
04/01 |
|
|
3617 |
AHC CARE/MI FEMALE 21-44 NO-MED |
04/01 |
|
|
3618 |
AHC CARE/MI M & F 45-64 NO-MED |
04/01 |
|
|
3619 |
AHC CARE/MI M & F 65+ NO-MED |
04/01 |
|
|
362A |
AHC CARE/MI M & F <1 W/QMB PPC |
04/01 |
|
|
362B |
AHC CARE/MI M & F 01-05 W/QMB PPC |
04/01 |
|
|
362C |
AHC CARE/MI M & F 06-13 W/QMB PPC |
04/01 |
|
|
362D |
AHC CARE/MI MALE 14-20 W/QMB PPC |
04/01 |
|
|
362E |
AHC CARE/MI FEMALE 14-20 W/QMB PPC |
04/01 |
|
|
362F |
AHC CARE/MI MALE 21-44 W/QMB PPC |
04/01 |
|
|
362G |
AHC CARE/MI FEMALE 21-44 W/QMB PPC |
04/01 |
|
|
362H |
AHC CARE/MI M & F 45-64 W/QMB PPC |
04/01 |
|
|
362J |
AHC CARE/MI M & F 65+ W/QMB PPC |
04/01 |
|
|
3621 |
AHC CARE/MI M & F <1 W/QMB |
04/01 |
|
|
3622 |
AHC CARE/MI M & F 01-05 W/QMB |
04/01 |
|
|
3623 |
AHC CARE/MI M & F 06-13 W/QMB |
04/01 |
|
|
3624 |
AHC CARE/MI MALE 14-20 W/QMB |
04/01 |
|
|
3625 |
AHC CARE/MI FEMALE 14-20 W/QMB |
04/01 |
|
|
3626 |
AHC CARE/MI MALE 21-44 W/QMB |
04/01 |
|
|
3627 |
AHC CARE/MI FEMALE 21-44 W/QMB |
04/01 |
|
|
3628 |
AHC CARE/MI M & F 45-64 W/QMB |
04/01 |
|
|
3629 |
AHC CARE/MI M & F 65+ W/QMB |
04/01 |
|
|
370A |
AHC CARE/MI HOSP M & F <1 W/MDC PPC |
10/01 |
|
|
370B |
AHC CARE/MI HOSP M & F 01-05 W/MDC PPC |
10/01 |
|
|
370C |
AHC CARE/MI HOSP M & F 06-13 W/MDC PPC |
10/01 |
|
|
370D |
AHC CARE/MI HOSP MALE 14-20 W/MDC PPC |
10/01 |
|
|
370E |
AHC CARE/MI HOSP FEMALE 14-20 W/MDC PPC |
10/01 |
|
|
370F |
AHC CARE/MI HOSP MALE 21-44 W/MDC PPC |
10/01 |
|
|
370G |
AHC CARE/MI HOSP FEMALE 21-44 W/MDC PPC |
10/01 |
|
|
370H |
AHC CARE/MI HOSP M & F 45-64 W/MDC PPC |
10/01 |
|
|
370J |
AHC CARE/MI HOSP M & F 65+ W/MDC PPC |
10/01 |
|
|
3701 |
AHC CARE/MI HOSP M & F <1 W/MDC |
10/01 |
|
|
3702 |
AHC CARE/MI HOSP M & F 01-05 W/MDC |
10/01 |
|
|
3703 |
AHC CARE/MI HOSP M & F 06-13 W/MDC |
10/01 |
|
|
3704 |
AHC CARE/MI HOSP MALE 14-20 W/MDC |
10/01 |
|
|
3705 |
AHC CARE/MI HOSP FEMALE 14-20 W/MDC |
10/01 |
|
|
3706 |
AHC CARE/MI HOSP MALE 21-44 W/MDC |
10/01 |
|
|
3707 |
AHC CARE/MI HOSP FEMALE 21-44 W/MDC |
10/01 |
|
|
3708 |
AHC CARE/MI HOSP M & F 45-64 W/MDC |
10/01 |
|
|
3709 |
AHC CARE/MI HOSP M & F 65+ W/MDC |
10/01 |
|
|
371A |
AHC CARE/MI HOSP M & F <1 NO-MED PPC |
10/01 |
|
|
371B |
AHC CARE/MI HOSP M & F 01-05 NO-MED PPC |
10/01 |
|
|
371C |
AHC CARE/MI HOSP M & F 06-13 NO-MED PPC |
10/01 |
|
|
371D |
AHC CARE/MI HOSP MALE 14-20 NO-MED PPC |
10/01 |
|
|
371E |
AHC CARE/MI HOSP FEMALE 14-20 NO-MED PPC |
10/01 |
|
|
371F |
AHC CARE/MI HOSP MALE 21-44 NO-MED PPC |
10/01 |
|
|
371G |
AHC CARE/MI HOSP FEMALE 21-44 NO-MED PPC |
10/01 |
|
|
371H |
AHC CARE/MI HOSP M & F 45-64 NO-MED PPC |
10/01 |
|
|
371J |
AHC CARE/MI HOSP M & F 65+ NO-MED PPC |
10/01 |
|
|
3711 |
AHC CARE/MI HOSP M & F <1 NO-MED |
10/01 |
|
|
3712 |
AHC CARE/MI HOSP M & F 01-05 NO-MED |
10/01 |
|
|
3713 |
AHC CARE/MI HOSP M & F 06-13 NO-MED |
10/01 |
|
|
3714 |
AHC CARE/MI HOSP MALE 14-20 NO-MED |
10/01 |
|
|
3715 |
AHC CARE/MI HOSP FEMALE 14-20 NO-MED |
10/01 |
|
|
3716 |
AHC CARE/MI HOSP MALE 21-44 NO-MED |
10/01 |
|
|
3717 |
AHC CARE/MI HOSP FEMALE 21-44 NO-MED |
10/01 |
|
|
3718 |
AHC CARE/MI HOSP M & F 45-64 NO-MED |
10/01 |
|
|
3719 |
AHC CARE/MI HOSP M & F 65+ NO-MED |
10/01 |
|
|
372A |
AHC CARE/MI HOSP M & F <1 W/QMB PPC |
10/01 |
|
|
372B |
AHC CARE/MI HOSP M & F 01-05 W/QMB PPC |
10/01 |
|
|
372C |
AHC CARE/MI HOSP M & F 06-13 W/QMB PPC |
10/01 |
|
|
372D |
AHC CARE/MI HOSP MALE 14-20 W/QMB PPC |
10/01 |
|
|
372E |
AHC CARE/MI HOSP FEMALE 14-20 W/QMB PPC |
10/01 |
|
|
372F |
AHC CARE/MI HOSP MALE 21-44 W/QMB PPC |
10/01 |
|
|
372G |
AHC CARE/MI HOSP FEMALE 21-44 W/QMB PPC |
10/01 |
|
|
372H |
AHC CARE/MI HOSP M & F 45-64 W/QMB PPC |
10/01 |
|
|
372J |
AHC CARE/MI HOSP M & F 65+ W/QMB PPC |
10/01 |
|
|
3721 |
AHC CARE/MI HOSP M & F <1 W/QMB |
10/01 |
|
|
3722 |
AHC CARE/MI HOSP M & F 01-05 W/QMB |
10/01 |
|
|
3723 |
AHC CARE/MI HOSP M & F 06-13 W/QMB |
10/01 |
|
|
3724 |
AHC CARE/MI HOSP MALE 14-20 W/QMB |
10/01 |
|
|
3725 |
AHC CARE/MI HOSP FEMALE 14-20 W/QMB |
10/01 |
|
|
3726 |
AHC CARE/MI HOSP MALE 21-44 W/QMB |
10/01 |
|
|
3727 |
AHC CARE/MI HOSP FEMALE 21-44 W/QMB |
10/01 |
|
|
3728 |
AHC CARE/MI HOSP M & F 45-64 W/QMB |
10/01 |
|
|
3729 |
AHC CARE/MI HOSP M & F 65+ W/QMB |
10/01 |
|
|
380Z |
MED HOSPITALIZED W/MDC PPC |
10/01 |
|
|
3800 |
MED HOSPITALIZED W/MDC |
10/01 |
|
|
381Z |
MED HOSPITALIZED NON-MDC PPC |
10/01 |
|
|
3810 |
MED HOSPITALIZED NON-MDC |
10/01 |
|
|
382Z |
MED HOSPITALIZED W/QMB PPC |
10/01 |
|
|
3820 |
MED HOSPITALIZED W/MDC |
10/01 |
Code |
Description | Eff Beg Date |
Eff End Date |
|
410A |
EAC < 1 M & F WITH MEDICARE PPC |
10/96 |
|
|
410B |
EAC 01-05 M & F WITH MEDICARE PPC |
10/96 |
|
|
410C |
EAC 06-13 M & F WITH MEDICARE PPC |
10/96 |
|
|
410D |
EAC 14-20 MALE WITH MEDICARE PPC |
10/96 |
|
|
410E |
EAC 14-20 FEMALE WITH MEDICARE PPC |
10/96 |
|
4100 |
EAC WITH MEDICARE | 01/87 |
09/97 |
|
4101 |
EAC <1 M & F WITH MEDICARE |
10/97 |
|
|
4102 |
EAC 01-05 M & F WITH MEDICARE |
10/97 |
|
|
4103 |
EAC 06-13 M & F WITH MEDICARE |
10/97 |
|
|
4104 |
EAC 14-20 MALE WITH MEDICARE |
10/96 |
|
|
4105 |
EAC 14-20 FEMALE WITH MEDICARE |
10/96 |
|
|
411A |
EAC < 1 M & F NON-MEDICARE PPC |
10/96 |
|
|
411B |
EAC 01-05 M & F NON-MEDICARE PPC |
10/96 |
|
|
411C |
EAC 06-13 M & F NON-MEDICARE PPC |
10/96 |
|
|
411D |
EAC 14-20 MALE NON-MEDICARE PPC |
10/96 |
|
|
411E |
EAC 14-20 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
4110 |
EAC NON-MEDICARE |
01/87 |
09/97 |
|
4111 |
EAC <1 M & F NON-MEDICARE |
10/97 |
|
|
4112 |
EAC 01-05 M & F NON-MEDICARE |
10/97 |
|
|
4113 |
EAC 06-13 M & F NON-MEDICARE |
10/97 |
|
|
4114 |
EAC 14-20 MALE NON-MEDICARE |
10/96 |
|
|
4115 |
EAC 14-20 FEMALE NON-MEDICARE |
10/96 |
|
|
420A |
ELIC < 1 M & F WITH MEDICARE PPC |
10/96 |
|
|
420B |
ELIC 01-05 M & F WITH MEDICARE PPC |
10/96 |
|
|
420C |
ELIC 06-13 M & F WITH MEDICARE PPC |
10/96 |
|
|
420D |
ELIC 14-20 MALE WITH MEDICARE PPC |
10/96 |
|
|
420E |
ELIC 14-20 FEMALE WITH MEDICARE PPC |
10/96 |
|
|
4200 |
ELIC WITH MEDICARE |
01/87 |
09/97 |
|
4201 |
ELIC <1 M & F WITH MEDICARE |
10/97 |
|
|
4202 |
ELIC 01-05 M & F WITH MEDICARE |
10/97 |
|
|
4203 |
ELIC 06-13 M & F WITH MEDICARE |
10/97 |
|
|
4204 |
ELIC 14-20 MALE WITH MEDICARE |
10/96 |
|
|
4205 |
ELIC 14-20 FEMALE WITH MEDICARE |
10/96 |
|
|
421A |
ELIC < 1 M & F NON-MEDICARE PPC |
10/96 |
|
|
421B |
ELIC 01-05 M & F NON-MEDICARE PPC |
10/96 |
|
|
421C |
ELIC 06-13 M & F NON-MEDICARE PPC |
10/96 |
|
|
421D |
ELIC 14-20 MALE NON-MEDICARE PPC |
10/96 |
|
|
421E |
ELIC 14-20 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
4210 |
ELIC NON-MEDICARE |
01/87 |
09/97 |
|
4211 |
ELIC <1 M & F NON-MEDICARE |
10/97 |
|
|
4212 |
ELIC 01-05 M & F NON-MEDICARE |
10/97 |
|
|
4213 |
ELIC 06-13 M & F NON-MEDICARE |
10/97 |
|
|
4214 |
ELIC 14-20 MALE NON-MEDICARE |
10/96 |
|
|
4215 |
ELIC 14-20 FEMALE NON-MEDICARE |
10/96 |
|
|
430A |
SOBRA CHILD < 1 M & F W/MEDICARE PPC |
10/96 |
|
|
430B |
SOBRA CHILD 01-05 M & F W/MEDICARE PPC |
10/96 |
|
|
430C |
SOBRA CHILD 06-13 M & F W/MEDICARE PPC |
10/96 |
|
|
430D |
SOBRA CHILD 14-20 MALE W/MEDICARE PPC |
10/96 |
|
|
430E |
SOBRA CHILD 14-20 FEMALE W/MEDICARE PPC |
10/96 |
|
|
4300 |
SOBRA CHILD WITH MEDICARE |
01/88 |
09/97 |
|
4301 |
SOBRA CHILD <1 M & F W/MEDICARE |
10/97 |
|
|
4302 |
SOBRA CHILD 01-05 M & F W/MEDICARE |
10/97 |
|
|
4303 |
SOBRA CHILD 06-13 M & F W/MEDICARE |
10/97 |
|
|
4304 |
SOBRA CHILD 14-20 MALE W/MEDICARE |
10/97 |
|
|
4305 |
SOBRA CHILD 14-20 FEMALE W/MEDICARE |
10/97 |
|
|
431A |
SOBRA CHILD < 1 M & F NON-MEDICARE PPC |
10/96 |
|
|
431B |
SOBRA CHILD 01-05 M & F NON-MEDICARE PPC |
10/96 |
|
|
431C |
SOBRA CHILD 06-13 M & NON-MEDICARE PPC |
10/96 |
|
|
431D |
SOBRA CHILD 14-20 MALE NON-MEDICARE PPC |
10/96 |
|
|
431E |
SOBRA CHILD 14-20 FEMALE NON-MEDICARE PP |
10/96 |
|
|
4310 |
SOBRA CHILD NON-MEDICARE |
01/88 |
09/97 |
|
4311 |
SOBRA CHILD <1 M & F NON-MEDICARE |
10/97 |
|
|
4312 |
SOBRA CHILD 01-05 M & F NON-MEDICARE |
10/97 |
|
|
4313 |
SOBRA CHILD 06-13 M & F NON-MEDICARE |
10/97 |
|
|
4314 |
SOBRA CHILD 14-20 MALE NON-MEDICARE |
10/97 |
|
|
4315 |
SOBRA CHILD 14-20 FEMALE NON-MEDICARE |
10/97 |
|
|
432A |
SOBRA CHILD < 1 M & F WITH QMB PPC |
10/96 |
|
|
432B |
SOBRA CHILD 01-05 M & F WITH QMB PPC |
10/96 |
|
|
432C |
SOBRA CHILD 06-13 M & F WITH QMB PPC |
10/96 |
|
|
432D |
SOBRA CHILD 14-20 MALE WITH QMB PPC |
10/96 |
|
|
432E |
SOBRA CHILD 14-20 FEMALE WITH QMB PPC |
10/96 |
|
|
4320 |
SOBRA CHILD WITH QMB |
01/88 |
09/97 |
|
4321 |
SOBRA CHILD <1 M & F WITH QMB |
10/97 |
|
|
4322 |
SOBRA CHILD 01-05 M & F WITH QMB |
10/97 |
|
|
4323 |
SOBRA CHILD 06-13 M & F WITH QMB |
10/97 |
|
|
4324 |
SOBRA CHILD 14-20 MALE WITH QMB |
10/97 |
|
|
4325 |
SOBRA CHILD 14-20 FEMALE WITH QMB |
10/97 |
|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
500C |
SOBRA PREG 09-13 FEMALE W/MEDICARE PPC |
10/96 |
|
|
500E |
SOBRA PREG 14-20 FEMALE W/MEDICARE PPC |
10/96 |
|
|
500G |
SOBRA PREG 21-44 FEMALE W/MEDICARE PPC |
10/96 |
|
|
500H |
SOBRA PREG 45-64 FEMALE W/MEDICARE PPC |
10/96 |
|
|
5000 |
SOBRA PREGNANT WOMAN WITH MEDICARE |
01/88 |
09/97 |
|
5003 |
SOBRA PREG 09-13 FEMALE WITH MEDICARE |
10/97 |
|
|
5005 |
SOBRA PREG 14-20 FEMALE WITH MEDICARE |
10/97 |
|
|
5007 |
SOBRA PREG 21-44 FEMALE WITH MEDICARE |
10/97 |
|
|
5008 |
SOBRA PREG 45-64 FEMALE WITH MEDICARE |
10/97 |
|
|
501C |
SOBRA PREG 09-13 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
501E |
SOBRA PREG 14-20 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
501G |
SOBRA PREG 21-44 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
501H |
SOBRA PREG 45-64 FEMALE NON-MEDICARE PPC |
10/96 |
|
|
5010 |
SOBRA PREGNANT WOMAN NON-MEDICARE |
01/88 |
09/97 |
|
5013 |
SOBRA PREG 09-13 FEMALE NON-MEDICARE |
10/97 |
|
|
5015 |
SOBRA PREG 14-20 FEMALE NON-MEDICARE |
10/97 |
|
|
5017 |
SOBRA PREG 21-44 FEMALE NON-MEDICARE |
10/97 |
|
|
5018 |
SOBRA PREG 45-64 FEMALE NON-MEDICARE |
10/97 |
|
|
502C |
SOBRA PREG 09-13 FEMALE WITH QMB PPC |
10/96 |
|
|
502E |
SOBRA PREG 14-20 FEMALE WITH QMB PPC |
10/96 |
|
|
502G |
SOBRA PREG 21-44 FEMALE WITH QMB PPC |
10/96 |
|
|
502H |
SOBRA PREG 45-64 FEMALE WITH QMB PPC |
10/96 |
|
|
5020 |
SOBRA PREGNANT WOMAN WITH QMB |
01/88 |
09/97 |
|
5023 |
SOBRA PREG 09-13 FEMALE WITH QMB |
10/97 |
|
|
5025 |
SOBRA PREG 14-20 FEMALE WITH QMB |
10/97 |
|
|
5027 |
SOBRA PREG 21-44 FEMALE WITH QMB |
10/97 |
|
|
5028 |
SOBRA PREG 45-64 FEMALE WITH QMB |
10/97 |
|
|
5500 |
SOBRA FPS FEMALE WITH MEDICARE |
10/97 |
|
|
5510 |
SOBRA FPS FEMALE WITH NON-MEDICARE |
10/97 |
|
|
5520 |
SOBRA FPS FEMALE WITH QMB |
10/97 |
|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
6011 |
KIDS <1 M/F NON-MEDICARE |
11/98 |
|
|
6012 |
KIDS 1-5 M&F NON-MEDICARE |
11/98 |
|
|
6013 |
KIDS 6-13 M&F NON-MEDICARE |
11/98 |
|
|
6014 |
KIDS 14-19 MALE NON-MEDICARE |
11/98 |
|
|
6015 |
KIDS 14-19 FEMALE NON-MEDICARE |
11/98 |
|
|
6514 |
SOBRA HIFA 14-20 MALE NON-MEDICARE |
10/01/02 |
|
|
6515 |
SOBRA HIFA 14-20 FEMALE NON-MEDICARE |
10/01/02 |
|
|
6516 |
SOBRA HIFA 21-44 MALE NON-MEDICARE |
10/01/02 |
|
|
6517 |
SOBRA HIFA 21-44 FEMALE NON-MEDICARE |
10/01/02 |
|
|
6518 |
SOBRA HIFA 45-64 MALE/FEMALE NON-MEDICARE |
10/01/02 |
|
|
6519 |
SOBRA HIFA 65+ MALE/FEMALE NON-MEDICARE |
10/01/02 |
|
|
6614 |
KC HIFA 14-20 MALE NON-MEDICARE |
10/01/02 |
|
|
6615 |
KC HIFA 14-20 FEMALE NON-MEDICARE |
10/01/02 |
|
|
6616 |
KC HIFA 21-44 MALE NON-MEDICARE |
10/01/02 |
|
|
6617 |
KC HIFA 21-44 FEMALE NON-MEDICARE |
10/01/02 |
|
|
6618 |
KC HIFA 45-64 MALE/FEMALE NON-MEDICARE |
10/01/02 |
|
|
6619 |
KC HIFA 65+ MALE/FEMALE NON-MEDICARE |
10/01/02 |
|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
7000 |
CMHS |
11/92 |
|
|
7100 |
SMI |
11/92 |
|
|
7200 |
CMHS/DD/18-20 |
11/92 |
|
|
7300 |
CMHS/SED |
11/92 |
|
|
7400 |
GENERAL MENTAL HEALTH SERVICES |
10/95 |
|
|
7600 |
SUBSTANCE ABUSE MENTAL HEALTH SERVICES |
10/95 |
|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
8020 |
QMB ONLY |
07/89 |
|
|
850Z |
SSI AGED TICKET/WORK W/MDC PPC |
10/01 |
|
|
8500 |
SSI AGED TICKET/WORK W/MDC |
10/01 |
|
|
851Z |
SSI AGED TICKET/WORK NON-MDC PPC |
10/01 |
|
|
8510 |
SSI AGED TICKET/WORK NON-MDC |
10/01 |
|
|
852Z |
SSI AGED TICKET/WORK W/QMB PPC |
10/01 |
|
|
8520 |
SSI AGED TICKET/WORK W/QMB |
10/01 |
|
|
860Z |
SSI BLIND TICKET/WORK W/MDC PPC |
10/01 |
|
|
8600 |
SSI BLIND TICKET/WORK W/MDC |
10/01 |
|
|
861Z |
SSI BLIND TICKET/WORK NON-MDC PPC |
10/01 |
|
|
8610 |
SSI BLIND TICKET/WORK NON-MDC |
10/01 |
|
|
862Z |
SSI BLIND TICKET/WORK W/QMB PPC |
10/01 |
|
|
8620 |
SSI BLIND TICKET/WORK W/QMB |
10/01 |
|
|
870Z |
SSI DISABLED TICKET/WORK W/MDC PPC |
10/01 |
|
|
8700 |
SSI DISABLED TICKET/WORK W/MDC |
10/01 |
|
|
871Z |
SSI DISABLED TICKET/WORK NON-MDC PPC |
10/01 |
|
|
8710 |
SSI DISABLED TICKET/WORK NON-MDC |
10/01 |
|
|
872Z |
SSI DISABLED TICKET/WORK W/QMB PPC |
10/01 |
|
|
8720 |
SSI DISABLED TICKET/WORK W/QMB |
10/01 |
|
Code |
Description |
Eff Beg Date |
Eff End Date |
|
9900 |
HOSPITALIZED KICK PAYMENT |
10/01 |
|
|
9910 |
TANF & SOBRA CHILDREN KICK PAYMENT |
10/99 |
|
|
9911 |
SB PAYMENT FOR TANF EXPANDED |
07/01 |
|
|
9920 |
SSI W/MEDICARE KICK PAYMENT |
10/99 |
|
|
9921 |
SSI W/O MEDICARE KICK PAYMENT |
10/99 |
|
|
9922 |
SB PAYMENT FOR SSI EXPANDED W/MDC |
04/01 |
|
|
9923 |
SB PAYMENT FOR SSI EXPANDED NO MDC |
04/01 |
|
|
9930 |
EAC/ELIC * MN/MI KICK PAYMENT |
10/99 |
|
|
9933 |
SB PAYMENT FOR AHCCCS CARE |
10/01 |
|
|
9934 |
SB PAYMENT FOR MED ELIGIBLES |
04/01 |
|
|
9935 |
SB PAYMENT FOR AHC CARE HOSPITALIZED |
10/01 |
|
|
9936 |
SB PAYMENT FOR AHC CARE/MI |
04/01 |
|
|
9937 |
SB PAYMENT FOR AHC CARE/MI HOSPITALIZED |
10/01 |
|
|
9938 |
SB PAYMENT FOR MED HOSPITALIZED |
10/01 |
|
|
9950 |
SOBRA WOMAN KICK PAYMENT |
10/99 |
|
|
9960 |
KIDSCARE KICK PAYMENT |
10/99 |
|
|
9990 |
SOBRA SUPPLEMENTAL PMT |
10/97 |
|
|
9997 |
SOBRA SUPP PAYMENT (SPEC. CAP) |
01/88 |
09/97 |
|
CODE |
DESCRIPTION |
A |
ABSENT PARENT (CSEA) |
|
C |
CHILD |
|
G |
GUARANTOR |
|
L |
LEGAL GUARDIAN |
|
O |
OTHER |
|
P |
PARENT |
|
S |
SELF |
|
CODE |
DESCRIPTION |
|
BB |
BED-BOUND |
|
CC |
LTC FACILITY CONV CARE |
|
CH |
CHEMOTHERAPY |
|
DI |
DIALYSIS |
|
ER |
ER-ACC/INJURY RELATED |
|
HA |
HOSPITALIZED-ACC/INJ REL |
|
HI |
HEAD INJURY |
|
HK |
HOSPITALIZED - KICK PAYMENT |
|
HS |
HOSPITALIZED |
|
NN |
NB-NORMAL |
|
OA |
OUTPATIENT-ACC/INJ RELAT |
|
PG |
PREGNANT |
|
PR |
PREGNANT-HIGH RISK |
|
RT |
RADIATION THERAPY |
|
SI |
SPINAL CORD INJURY |
|
SN |
NB-SICK |
|
ST |
SURGICAL STERILIZATION |
|
TP |
TRANSPLANTS |
|
COUNTY |
DESCRIPTION |
GSA |
|
01 |
APACHE |
16 |
|
03 |
COCHISE |
18 |
|
05 |
COCONINO |
06 |
|
07 |
GILA |
08 |
|
09 |
GRAHAM |
14 |
|
11 |
GREENLEE |
14 |
|
13 |
MARICOPA |
12 |
|
15 |
MOHAVE |
04 |
|
17 |
NAVAJO |
16 |
|
19 |
PIMA |
10 |
|
21 |
PINAL |
08 |
|
23 |
SANTA CRUZ |
18 |
|
25 |
YAVAPAI |
06 |
|
27 |
YUMA |
02 |
|
29 |
LA PAZ |
04 |
|
31 |
OUT OF STATE | |
|
33 |
OUT OF COUNTRY | |
|
35 |
UNKNOWN | |
|
99 |
STATEWIDE (FOR PRICING) |
|
CODE |
DESCRIPTION |
TYPE |
INDICATOR |
|
$P |
MANUAL PAYMENT |
A |
Y |
|
$R |
MANUAL RECOUPMENT |
D |
Y |
|
AA |
ALGORITHM ASSIGNED |
A |
N |
|
AC |
ADDRESS CHANGE |
C |
N |
|
AE |
APPLIED FOR NEW ELIGIBLITY |
D |
Y |
|
AI |
ADMIN-IN |
A |
N |
|
AO |
ADMIN-OUT |
D |
Y |
|
BI |
ENROLLMENT BLOCK IN |
A |
N |
|
BO |
ENROLLMENT BLOCK OUT |
D |
Y |
|
CH |
ELIG CHANGE CAUSES DISENRL |
D |
Y |
|
CI |
COUNTY MOVE-IN |
A |
N |
|
CO |
COUNTY MOVE-OUT |
D |
Y |
|
DB |
DATE OF BIRTH CHANGE |
C |
N |
|
DE |
DECEASED |
D |
Y |
|
EC |
ENROLLMENT CHOICE |
A |
N |
|
EI |
OPEN ENROLLMENT-IN |
A |
N |
|
EO |
OPEN ENROLLMENT-OUT |
D |
Y |
|
FI |
FAMILY CONTINUITY-IN |
A |
N |
|
FO |
FAMILY CONTINUITY-OUT |
D |
Y |
|
HC |
ACUTE HEALTH PLAN CHANGE |
C |
N |
|
HK |
HOSPITALIZED, KICK TO BE PAID | ||
|
HO |
MOVE OUT OF HEALTH PLAN AREA |
D |
Y |
|
IE |
INELIGIBLE |
D |
Y |
|
MA |
MASS ADJUSTMENT RECOUPMENT |
D |
Y |
|
MC |
MENTAL HEALTH CHANGE |
C |
N |
|
MI |
MEDICAL CARE CONTINUITY-IN |
A |
N |
|
MO |
MEDICAL CARE CONTINUITY-OUT |
D |
Y |
|
MR |
MASS ADJUSTMENT PAYMENT |
A |
Y |
|
NB |
NEWBORN |
A |
N |
|
NC |
NAME CHANGE |
C |
N |
|
NE |
NORMAL ENROLLMENT |
A |
N |
|
NP |
NORMAL ENROLLMENT-PRIOR PLAN |
A |
N |
|
OS |
OUT OF STATE MOVE |
D |
Y |
|
PA |
END OF CONTRACT-IN: AUTO ASSIGN |
A |
N |
|
PD |
END OF CONTRACT-IN: DIRECT MOVE |
A |
N |
|
PG |
PREGNANT WOMEN |
C |
N |
|
PO |
END OF CONTRACT-OUT: DIRECT MOVE |
D |
Y |
|
PP |
END OF CONTRACT-IN: PERCENTAGE |
A |
N |
|
PR |
END OF CONTRACT-IN: RULE MATRIX |
A |
N |
|
PT |
END OF CONTRACT-OUT: %, AUTO, RULE |
D |
Y |
|
RA |
RETROACTIVE ENROLLMENT |
A |
N |
|
RC |
RATE CODE CHANGE |
C |
N |
|
RE |
RE-ENROLLMENT |
A |
N |
|
RO |
RECOUPMENT MHS |
D |
Y |
|
SB |
SUPPLEMENTAL BIRTH PAYMENT |
C |
N |
|
SC |
SHARE OF COST CHANGE |
C |
N |
|
SX |
SEX CHANGE |
C |
N |
|
TM |
MENTAL HEALTH TERMINATION |
C |
N |
|
VW |
VOLUNTARY WITHDRAWAL |
D |
Y |
|
Type |
Contract |
Description |
CAP |
FFS |
|
% |
CRS/CAP |
Children's Rehab Services, Capitation |
Y |
N |
|
@ |
DES/DD/RI |
DES DD Reinsurance Indicator |
N |
N |
|
A |
ACU/CAP |
Acute Capitated |
Y |
N |
|
B |
ACU/CAP/PAR |
Acute Partially Capitated |
Y |
Y |
|
C |
ACU/CAP/ACU |
Acute Capitated Acute SVCS Only |
Y |
N |
|
D |
ACU/FFS/ACU |
Acute Fee for Service Acute Only |
N |
Y |
|
E |
ACU/FFS |
Acute Fee for Service |
N |
Y |
|
F |
ACU/FFS/EMO |
Acute FFS Emergency Services Only |
N |
Y |
|
G |
ACU/FFS/FPS |
Acute Fee For Service, Family Planning Services |
N |
Y |
|
H |
ACU/PPC |
Acute Prior Period Coverage |
Y |
N |
|
I |
ACU/PPC/EMO |
Acute Prior Period Coverage Emergency Svcs |
Y |
N |
|
J |
LTC/CAP |
Long Term Care Capitated |
Y |
N |
|
K |
MHS/CAP/ACU |
Mental Health Svcs, Cap Acute Only |
Y |
N |
|
L |
LTC/CAP/ACU |
Long Term Care Cap Acute Only |
Y |
N |
|
M |
LTC/PPC |
Long Term Care Prior Period Coverage |
Y |
N |
|
N |
ACU/NBN |
Acute Newborn Non-Capped |
N |
N |
|
O |
LTC/PPC/ACU |
Long Term Care Prior Period Coverage Acute |
Y |
N |
|
P |
LTC/CAP/PAR |
Long Term Care Partial Cap |
Y |
Y |
|
Q |
ACU/CAP/FPS |
Acute Capitated FPS Only |
Y |
N |
|
R |
LTC/FFS |
Long Term Care FFS |
N |
Y |
|
S |
MHS/CAP/DD |
Mental Health Services Cap DD |
Y |
N |
|
T |
LTC/FFS/ACU |
Long Term Care FFS Acute Only |
Y |
Y |
|
U |
UNDOC/FFS/EM |
Undoc. Aliens, FFS, Emg Svc Only |
N |
Y |
|
V |
MHS/Cap/KC |
Mental Health Services Capitated Kidscare |
Y |
N |
|
W |
ACU/KC/NoPay |
ADHS Direct Services Kidscare No Payment |
N |
N |
|
X |
ACU/FFS/KC |
Acute FFS Kidscare |
N |
Y |
|
Y |
ACU/CAP/KC |
Acute Capitated Kidscare |
Y |
N |
|
2 |
LTC/VD/CAP/F |
LTC Vent Dependent Cap Full Svc |
Y |
N |
|
3 |
LTC/FFS/VD |
Long Term Care FFS VD |
Y |
Y |
|
4 |
LTC/VD/CAP/A |
LTC Vent Dependent Cap Acute Svc |
Y |
N |
|
5 |
LTC/FFS/VHA |
Long Term Care FFS VD Acute Only |
Y |
Y |
|
8 |
NON/PAY |
No Payment Permitted |
N |
N |
|
CODE |
DESCRIPTION |
|
AF |
AFDC |
|
EA |
EAC |
|
EL |
ELIC |
|
FP |
SOBRA Women Family Planning Services |
|
MI |
Medically Indigent |
|
MN |
Medically Needy |
|
QA |
QMB Only Aged |
|
QB |
QMB Only Blind |
|
QD |
QMB Only Disabled |
|
QO |
QMB Only Other |
|
SA |
SSI Aged |
|
SB |
SSI Blind |
|
SD |
SSI Disabled |
|
SF |
State Funded |
|
SI |
SSI |
|
SO |
Sobra Woman |
|
TA |
TANF |