L2: Facility type

Resolve the payment system, billing form, and type of bill codes from the facility type encoded in a CCN

Layer 2 reads digits 3-4 of the CCN to determine the facility type, then resolves the applicable Medicare payment system, required billing form, and type of bill (TOB) codes. This determines how you bill — not just what you bill.

How it works

CCN: 170001
        ^^
        00 → Short-Term Acute Care Hospital

The facility type code maps to a provider category, which in turn determines which prospective payment system applies and which claim form to use.

Request

curl https://api-dev.rcintell.com/v1/knowledge/layers/170001/l2 \
  -H "X-API-Key: $RCI_API_KEY"

Response

{
  "layer": "l2_facility_type",
  "data": {
    "facility_type_key": "short_term_acute",
    "facility_type_name": "Short-Term Acute Care Hospital",
    "payment_system": "Inpatient Prospective Payment System (IPPS) / Outpatient Prospective Payment System (OPPS)",
    "inpatient_pps": "MS-DRG based",
    "outpatient_pps": "APC based",
    "billing_form": "UB-04 (CMS-1450) / 837I",
    "tob_inpatient": "011x",
    "tob_outpatient": "013x"
  }
}

Facility type ranges

The facility type code (CCN digits 3-4) determines the provider category:

Code range	Facility type	Payment system
00-12	Short-Term Acute Care Hospital	IPPS (inpatient) / OPPS (outpatient)
13	Critical Access Hospital (CAH)	Cost-based (101% of reasonable costs)
14-19	Short-Term Acute Care Hospital	IPPS / OPPS
20-22	Long-Term Care Hospital (LTCH)	LTCH PPS (MS-LTC-DRG)
30-39	Home Health Agency	HH PPS (PDGM, 30-day periods)
40-49	Skilled Nursing Facility (SNF)	SNF PPS (PDPM)
50-64	Rehabilitation Facility	IRF PPS (Case-Mix Groups)
65-69	Psychiatric Hospital	IPF PPS
70-79	Federally Qualified Health Center	FQHC PPS
80-89	Hospice	Per-diem rates

Payment systems

Each facility type has a different Medicare payment methodology:

IPPS / OPPS

Short-term hospitals use MS-DRG (inpatient) or APC (outpatient) payment groups. The most common facility type.

Cost-based (CAH)

Critical Access Hospitals are reimbursed at 101% of reasonable costs — no DRG grouping.

HH PPS

Home health uses the Patient-Driven Groupings Model (PDGM) with 30-day payment periods and 432 case-mix groups.

SNF PPS

Skilled nursing uses the Patient-Driven Payment Model (PDPM) with consolidated billing — the SNF is responsible for almost all Part A and B services.

Billing form rules

Facility type	Claim form	Electronic format	When to use
Hospital (all types)	UB-04 (CMS-1450)	837I	Institutional claims
Home Health	UB-04 (CMS-1450)	837I	Episode claims, RAPs
SNF	UB-04 (CMS-1450)	837I	Consolidated billing
FQHC	UB-04 (CMS-1450)	837I	All-inclusive rate
Physician (office)	CMS-1500	837P	Professional claims

Almost all facility types use the UB-04 / 837I for institutional claims. The CMS-1500 / 837P is used for professional claims billed by individual physicians, regardless of where the service was performed.

Type of bill codes

The TOB code is a 4-digit code on the UB-04 that identifies the type of facility, type of care, and billing frequency:

Digit	Position	Meaning
0	1st	Always 0 (leading zero)
1-8	2nd	Facility type
1-9	3rd	Classification (inpatient, outpatient, etc.)
0-9	4th	Frequency (admit through discharge, interim, replacement, etc.)

Common TOB codes

TOB	Meaning
011x	Hospital inpatient (Part A)
013x	Hospital outpatient
021x	SNF inpatient (Part A)
0329	Home health — not under PPS plan of care
077x	FQHC
081x	Hospice (non-hospital based)
085x	CAH outpatient

Using the wrong TOB code is one of the most common reasons for claim rejections. Always use the TOB returned by the L2 layer for your facility type — don’t assume based on the service alone.