CMS Pub. 100-05, ch. 6, § 60

(HIPAA) Individual Relationship Codes to Common Working File

(CWF) Medicare Secondary Payer (MSP) Patient Relationship Codes

(Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23)

CMS has realized that its Common Working File (CWF) HUSP transaction does not

allow for the correct association of HIPAA individual relationship codes, as found in the

HIPAA 837 institutional and professional claims implementation guides, with

corresponding MSP Type Codes, such as working aged (A), end-stage renal disease (B),

and disability (G). Therefore, effective July 6, 2004, all A/B MACs (A) that receive

incoming electronic HIPAA, DDE, or hard copy claims that are in the HIPAA ASC X12

837 format shall convert the incoming individual relationship codes to their equivalent

CWF patient relationship codes. Until further notice, A/B MACs (A) shall continue to

operate under the working assumption that all providers will be including HIPAA

individual relationship codes on incoming claims.

Before CMS’ systems changes are effectuated, A/B MACs (A) may receive SP edits (i.e.,

SP-33 and SP-52) that indicate that an invalid patient relationship code was applied. A/B

MACs (A) are to resolve those edits by manually converting the HIPAA individual

relationship code to the CWF patient relationship code, as specified in the conversion

chart below. If the A/B MAC (A) receives MSP edits and can determine that the HIPAA

individual relationship code rather than the CWF patient relationship code was submitted

on the incoming claim, it shall manually work the MSP edits incurred by converting the

HIPAA individual relationship code to the appropriate CWF patient relationship code.

Until Part A shared system changes are effectuated to convert HIPAA individual

relationship codes to CWF patient relationship codes, A/B MACs (A) may move claims

with a systems age of 30 days or older that have suspended for resolution of patient

relationship code, including SP-33 or SP-52 edits, to condition code 15 (CC-15).

The A/B MAC (A) contractor system shall utilize the conversion charts, found below, to

cross-walk incoming HIPAA individual relationship codes to the CWF patient

relationship code values.

For MSP Occurrences with accretion dates PRIOR to 4/4/2011:

HIPAA

Individual

Relationship

Codes

Convert To CWF

Patient Relationship

Codes

Valid Values

18 01 Patient is Insured

01 02 Spouse

19 03 Natural Child, Insured has financial

responsibility

43 04 Natural Child, insured does not have

financial responsibility

17 05 Step Child

10 06 Foster Child

15 07 Ward of the Court

20 08 Employee

21 09 Unknown

22 10 Handicapped Dependent

39 11 Organ donor

40 12 Cadaver donor

05 13 Grandchild

HIPAA

Individual

Relationship

Codes

Convert To CWF

Patient Relationship

Codes

Valid Values

07 14 Niece/Nephew

41 15 Injured Plaintiff

23 16 Sponsored Dependent

24 17 Minor Dependent of a Minor

Dependent

32,33 18 Parent

04 19 Grandparent

53 20 Life Partner

29 N/A Significant Other

30 N/A ?

31 N/A ?

36 N/A ?

G8 N/A ?

Other HIPAA

Individual

Relationship Codes

N/A ?

For MSP Occurrences with accretion dates 4/4/2011 AND SUBSEQUENT:

HIPAA

Individual

Relationship

Codes

Convert To CWF

Patient Relationship

Codes

Description

18 01 Self; Beneficiary is the policy holder

or subscriber for the other GHP

insurance reflected by the MSP

occurrence –or- Beneficiary is the

injured party on the Workers

Compensation, No-Fault, or Liability

claim

01 02 Spouse

19 03 Child

43 03 Child

17 03 Child

10 03 Child

15 04 Other

20 04 Other

21 04 Other

22 04 Other

39 04 Other

HIPAA

Individual

Relationship

Codes

Convert To CWF

Patient Relationship

Codes

Description

40 04 Other

05 04 Other

07 04 Other

41 01 Self; Beneficiary is the policy holder

or subscriber for the other GHP

insurance reflected by the MSP

occurrence –or- Beneficiary is the

injured party on the Workers

Compensation, No-Fault, or Liability

claim

23 04 Other

24 04 Other

32,33 04 Other

04 04 Other

53 20 Life Partner

29 N/A Significant Other

30 N/A ?

31 N/A ?

36 N/A ?

G8 N/A ?

Other HIPAA

Individual

Relationship Codes

N/A ?

A/B MACs (A) allow CWF patient relationship codes, since these files should be

populated with information sent back to the A/B MACs (A)’ systems via the automated

transaction.