STANDARD DATA DICTIONARY #355.1 -- TYPE OF PLAN FILE 3/24/25 PAGE 1
STORED IN ^IBE(355.1, (63 ENTRIES) SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file contains the standard types of plans that an insurance company may provide. The type of plan may be dependent on the
type of coverage provided by the insurance company and may affect the type of benefits that are available for the plan.
Per VHA Directive 10-93-142, this file definition should not be modified.
DD ACCESS: @
WR ACCESS: @
DEL ACCESS: @
LAYGO ACCESS: @
AUDIT ACCESS: @
IDENTIFIED BY: MAJOR CATEGORY (#.03)
POINTED TO BY: TYPE OF PLAN field (#.09) of the GROUP INSURANCE PLAN File (#355.3)
TYPE OF PLAN field (#40.09) of the INSURANCE VERIFICATION PROCESSOR File (#355.33)
TYPE OF PLAN field (#.08) of the ORIGINATING VAMC sub-field (#365.192) of the INTERFACILITY INSURANCE UPDATE File
(#365.19)
CROSS
REFERENCED BY: MAJOR CATEGORY(C), ABBREVIATION(D), MASTER TYPE OF PLAN(MTOP)
INDEXED BY: NAME (B)
LAST MODIFIED: JAN 30,2018@15:39:52
355.1,.01 NAME 0;1 FREE TEXT (Required)
INPUT TRANSFORM: K:$L(X)>70!($L(X)<3)!'(X'?1P.E) X
LAST EDITED: MAY 06, 2015
HELP-PROMPT: Enter the standard abbreviation. Answer must be 2-70 characters in length.
DESCRIPTION: There are a number of different types of policies, some have very specific types of coverage while
others cover a much broader range of care. This is the name of the type of policy. Select the
name that best describes the type of policy. This is a list of standard types of policies.
The type of policy may be dependent on the type of coverage provided by the insurance company and
may affect the type of benefits that are available for the policy. This will be used in
determining if the reimbursement from the insurance company is appropriate for this policy.
FIELD INDEX: B (#851) REGULAR IR LOOKUP & SORTING
Short Descr: "B" Regular Cross-Reference of .01 field
Description: The "B" cross-reference has been updated to allow for a full 70-character lookup instead of being
limited to the first 30 characters. This is done to prevent a potential lookup error by Fileman DBS
calls.
Set Logic: S ^IBE(355.1,"B",$E(X,1,70),DA)=""
Kill Logic: K ^IBE(355.1,"B",$E(X,1,70),DA)
Whole Kill: K ^IBE(355.1,"B")
X(1): NAME (355.1,.01) (Subscr 1) (Len 70) (forwards)
355.1,.02 ABBREVIATION 0;2 FREE TEXT
INPUT TRANSFORM: K:$L(X)>12!($L(X)<2) X
LAST EDITED: MAY 07, 2015
HELP-PROMPT: Enter the standard abbreviation. Answer must be 2-12 characters in length.
DESCRIPTION: Enter the standard abbreviation for this type of policy. The abbreviation will be used on standard
displays of policy information where space is limited.
CROSS-REFERENCE: 355.1^D
1)= S ^IBE(355.1,"D",$E(X,1,30),DA)=""
2)= K ^IBE(355.1,"D",$E(X,1,30),DA)
This cross-reference allows the Type of Plan to be found by the abbreviation.
355.1,.03 MAJOR CATEGORY 0;3 SET
'1' FOR MAJOR MEDICAL;
'2' FOR DENTAL;
'3' FOR HMO;
'4' FOR PPO;
'5' FOR MEDICARE;
'6' FOR MEDICAIDE;
'7' FOR CHAMPUS;
'8' FOR WORKMANS COMP;
'9' FOR INDEMNITY;
'10' FOR PRESCRIPTION;
'11' FOR MEDICARE SUPPLEMENTAL;
'12' FOR ALL OTHER;
LAST EDITED: JAN 11, 1994
DESCRIPTION: Each type of policy must be identified with a major category. It is the major category field that
will be used to determine the type of policy internally by the computer.
WRITE AUTHORITY: @
CROSS-REFERENCE: 355.1^C
1)= S ^IBE(355.1,"C",$E(X,1,30),DA)=""
2)= K ^IBE(355.1,"C",$E(X,1,30),DA)
355.1,.04 INACTIVE 0;4 SET
'1' FOR YES;
LAST EDITED: AUG 11, 1997
HELP-PROMPT: Enter Yes if this Type of Plan should be Inactivated.
DESCRIPTION:
An Inactive Type of Plan should no longer be used to define Plans.
355.1,10 DESCRIPTION 10;0 WORD-PROCESSING #355.11
DESCRIPTION:
Enter a one or two sentence description of the type of policy.
LAST EDITED: JUN 03, 1993
355.1,14 EFFECTIVE DATE 14;0 DATE Multiple #355.14
DESCRIPTION: The effective date multiple contains the date(s) on which the coverage amounts paid by a
supplemental Type of Plan go into effect or change. The percentages paid are stored within this
Effective Date multiple by Group Code and Reason Code. When these percentages change, a new
effective date should be entered along with each Group and Reason Code for which this plan pays.
If there is no effective date entry or the effective date is AFTER the claim service From date, the
secondary balance due will be calculated as 100% of Patient Responsibility as indicated on the
Medicare-equivalent Remittance Advice (MRA).
TECHNICAL DESCR: If the Type of Plan assigned to the insurance plan on a claim, has an effective date on or before
the claim service From date: (File#399 Field#151 FIELD NAME: STATEMENT COVERS FROM Global
Location: U;1) the balance due for the secondary claim will be based on the patient responsibility
multiplied by any percentages stored in the effective date multiple, plus excess charges if
applicable. If there is no effective date entry or the effective date is AFTER the claim From
service date, the secondary balance due will be calculated as 100% of Patient Responsibility as
indicated on the Medicare-equivalent Remittance Advice.
INDEXED BY: PART A PERCENTAGE & PART B PERCENTAGE & REASON CODE (AEDT)
355.14,.01 EFFECTIVE DATE 0;1 DATE
INPUT TRANSFORM: S %DT="EX" D ^%DT S X=Y K:Y<1 X
LAST EDITED: MAY 10, 2011
HELP-PROMPT: Enter the date the Type Of Plan Percentages paid became effective.
DESCRIPTION: This is the date on which the coverage amounts paid by a supplemental Type of Plan go into
effect. The percentages paid are stored by Date, Group Code and Reason Code. When these
percentages change, a new effective date should be entered along with each Group and Reason Code
for which this plan pays. If there is no effective date entry or the effective date is AFTER the
claim service From date, the secondary balance due will be calculated as 100% of Patient
Responsibility as indicated on the Medicare-equivalent Remittance Advice (MRA).
UNEDITABLE
CROSS-REFERENCE: 355.14^B
1)= S ^IBE(355.1,DA(1),14,"B",$E(X,1,30),DA)=""
2)= K ^IBE(355.1,DA(1),14,"B",$E(X,1,30),DA)
355.14,1 GROUP CODE 1;0 SET Multiple #355.141
DESCRIPTION: These are the group code(s) for which this type of plan pays all or a percentage of the
adjustments made to the original claim by the payer during adjudication. For example, if there
is an entry for Group Code CO, this plan pays all or part of Excess Charges.
TECHNICAL DESCR: If the claim's Type of Plan entry has an effective date on or before the claim service From date,
the balance due for the secondary claim will be based on the patient responsibility multiplied by
any percentages stored in the effective date multiple, plus excess charges if the Group Code CO
is contained within this multiple. Claim Service From Date is: File #399 Field #151 FIELD NAME:
STATEMENT COVERS FROM Global Location:U;1
355.141,.01 GROUP CODE 0;1 SET (Required) (Multiply asked)
'CO' FOR Contractual Obligations;
'CR' FOR Corrections and Reversals;
'OA' FOR Other Adjustments;
'PI' FOR Payor Initiated Reductions;
'PR' FOR Patient Responsibility;
'MM' FOR Medicare Message;
LAST EDITED: MAY 12, 2011
HELP-PROMPT: Enter a valid group code covered by this type of plan.
DESCRIPTION: This is the group code for which this type of plan pays all or a percentage of the adjustments
made to the original claim by the payer during adjudication. For example, if there is an entry
for Group Code CO, this plan pays all or part of Excess Charges.
UNEDITABLE
CROSS-REFERENCE: 355.141^B
1)= S ^IBE(355.1,DA(2),14,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^IBE(355.1,DA(2),14,DA(1),1,"B",$E(X,1,30),DA)
355.141,1 REASON CODE 1;0 Multiple #355.1411
DESCRIPTION: This multiple stores the Reason Code(s) for which, when associated with the correct Group Code,
this Type of Plan pays all or a percentage of the adjustments made to the original claim by the
payer during adjudication. For example, if there is an entry of Reason Code 1 with the Group
Code of PR, then this plan pays all or a percentage of the Patient's Deductable as indicated on
the Medicare-equivalent Remittance Advice (MRA).
TECHNICAL DESCR: If the claim's type of plan entry has an effective date on or before the claim service From
date, the balance due for the secondary claim will be based on the patient responsibility
multiplied by any percentages stored in the effective date multiple, plus excess charges if the
Group Code CO is contained within this multiple and is associated with the correct Reason Code.
355.1411,.01 REASON CODE 0;1 FREE TEXT (Required) (Multiply asked)
INPUT TRANSFORM: K:$L(X)>4!($L(X)<1) X
LAST EDITED: MAY 12, 2011
HELP-PROMPT: Answer must be 1-4 characters in length.
DESCRIPTION: This is the Reason Code for which, when associated with the correct Group Code, this Type of
Plan pays all or a percentage of the adjustments made to the original claim by the payer
during adjudication. Example, if there is an entry of Reason Code 1 with the Group Code of
PR, then this plan pays all or a percentage of the Patient's Deductable as indicated on the
Medicare-equivalent Remittance Advice (MRA).
TECHNICAL DESCR: If the claim's Type of Plan entry has an effective date on or before the claim service From
date, the balance due for the secondary claim will be based on the patient responsibility
multiplied by any percentages stored in the effective date multiple underneath the
appropriate reason codes, plus excess charges if the Group Code CO is contained within this
multiple and is associated with the correct Reason Code.
UNEDITABLE
CROSS-REFERENCE: 355.1411^B
1)= S ^IBE(355.1,DA(3),14,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)=""
2)= K ^IBE(355.1,DA(3),14,DA(2),1,DA(1),1,"B",$E(X,1,30),DA)
RECORD INDEXES: AEDT (#987) (WHOLE FILE #355.14)
355.1411,1 PART A PERCENTAGE 0;2 NUMBER (Required)
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1.N) X
LAST EDITED: MAY 10, 2011
HELP-PROMPT: Type a number between 0 and 100, 0 decimal digits.
DESCRIPTION: This is the percentage (0-100) that this Type of Plan pays for PART A amounts returned under
a Group and Reason code on an MRA. Example, if this plan pays 50% of the Part A Deductible,
enter a Group Code of PR in the Group Code multiple, a Reason Code of 1 in the Reason Code
multiple,
and a 50 in this field.
TECHNICAL DESCR: If the claim's type of plan entry has an effective date on or before the claim service date,
the balance due for the secondary claim will be based on the patient responsibility
multiplied by any percentages stored in the effective date multiple, plus excess charges if
the Group Code CO is contained within this multiple and is associated with the correct Reason
Code. Part A charges are calculated on Inpatient Institutional Claims.
UNEDITABLE
RECORD INDEXES: AEDT (#987) (WHOLE FILE #355.14)
355.1411,2 PART B PERCENTAGE 0;3 NUMBER (Required)
INPUT TRANSFORM: K:+X'=X!(X>100)!(X<0)!(X?.E1"."1N.N) X
LAST EDITED: MAY 10, 2011
HELP-PROMPT: Type a number between 0 and 100, 0 decimal digits.
DESCRIPTION: This is the percentage (0-100) that this plan pays for PART B amounts returned under a Group
and Reason code on an MRA. Example, if this plan pays 75% of Part B Co-payments, enter a
Group Code of PR in the Group Code multiple,a Reason Code of 2 in the Reason Code multiple,
and a 75 in this field.
TECHNICAL DESCR: If the claim's Type of Plan entry has an effective date on or before the claim service From
date, the balance due for the secondary claim will be based on the patient responsibility
multiplied by any percentages stored in the effective date multiple, plus excess changes if
the Group Code of CO is contained within this multiple and is associated with the correct
Reason Code. Part B charges are calculated on Outpatient Institutional claims and all
Professional claims.
UNEDITABLE
RECORD INDEXES: AEDT (#987) (WHOLE FILE #355.14)
355.1,15 MASTER TYPE OF PLAN 0;5 POINTER TO MASTER TYPE OF PLAN FILE (#355.99)
INPUT TRANSFORM: S DIC("S")="I '$$SCREEN^XTID(355.99,.01,+Y_"","")" D ^DIC K DIC S DIC=DIE,X=+Y K:Y<0 X
LAST EDITED: AUG 30, 2017
HELP-PROMPT: Enter the Master Type of Plan (MTOP) PHDSC Source of Payment associated with the Type of Plan.
NOTE: MTOP names are case sensitive.
DESCRIPTION: This field points to the MASTER TYPE OF PLAN file (#355.99). This is a link to the national
standard names for source of payment.
SCREEN: S DIC("S")="I '$$SCREEN^XTID(355.99,.01,+Y_"","")"
EXPLANATION: Only active Master Type of Plan entries may be selected.
CROSS-REFERENCE: 355.1^MTOP
1)= S ^IBE(355.1,"MTOP",$E(X,1,30),DA)=""
2)= K ^IBE(355.1,"MTOP",$E(X,1,30),DA)
This cross references MASTER TYPE OF PLAN (#15) field entries.
FILES POINTED TO FIELDS
MASTER TYPE OF PLAN (#355.99) MASTER TYPE OF PLAN (#15)
Subfile #355.1411
Record Indexes:
AEDT (#987) RECORD MUMPS IR SORTING ONLY WHOLE FILE (#355.14)
Short Descr: Effective Date Index
Description: This index is used to find the part A and B percentages paid for a type of plan based on the group and reason
codes entered on the MRA. This index uses computed code: X(3): Computed Code: S
X=$P($G(^IBE(355.1,DA(3),14,DA(2),0)),U) which sets X(3) = to the external value of the Group Code and X(4):
Computed Code: S X=$P($G(^IBE(355.1,DA(3),14,DA(2),1,DA(1),0)),U) which sets X(4) = to the external value of
the Reason Code. This allows for an efficient match between the Group and Reason Codes on the patient's MRA
and the Group and Reason Codes for the patient's supplemental type of plan.
Set Logic: S ^IBE(355.1,DA(3),14,"AEDT",X(3),X(4),X(5))=X(1)_U_X(2)
Kill Logic: K ^IBE(355.1,DA(3),14,"AEDT",X(3),X(4),X(5))
X(1): PART A PERCENTAGE (355.1411,1) (forwards)
X(2): PART B PERCENTAGE (355.1411,2) (forwards)
X(3): Computed Code: S X=$P($G(^IBE(355.1,DA(3),14,DA(2),0)),U)
X(4): Computed Code: S X=$P($G(^IBE(355.1,DA(3),14,DA(2),1,DA(1),0)),U)
X(5): REASON CODE (355.1411,.01) (forwards)
INPUT TEMPLATE(S):
IB TOPM AUG 30, 2017@13:37 USER #0
Allow write access to the MASTER TYPE OF PLAN field (#15) in the TYPE OF
PLAN file (#355.1) to associate the Plan Types to Master Plan Types.
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):