Administrative Requirements for Section 6071 of the DRA (CMS-10249)

TABLE 1 (continued)

TABLE 2
PROPOSED CONTENT FOR MFP-SERVICES FILE

Data Element	Description
Adjustment indicator	Code indicating type of adjustment record
Amount charged	The total charge for this claim as submitted by the provider
Beginning date of service	The date on which the service covered by this claim began
Date of payment – adjudication	The date on which the payment status of the claim was finally adjudicated
Diagnosis code (up to 9 occurrences)	Diagnosis codes that appear on the bill; many types of claims are not expected to have diagnosis codes
Ending date of service	The date on which the service covered by this claim ended
Amount paid	The amount paid by the MFP demonstration on this claim or adjustment
MSIS identification number	The person’s unique identification number used to identify a Medicaid eligible
Other third party payment	The total amount paid by all sources other than Medicaid, Medicare, and the recipient’s personal funds
Place of service	A code indicating where the service was performed
Plan identification number	A unique number which represents the health plan under which the non-fee-for-service encounter was provided
Program type	Code indicating special Medicaid program under which the service was provided (e.g., HCB waiver service) ?????
Provider identification number – billing	A unique identification number assigned by the state to a provider or capitation plan billing for the service
Provider identification number – servicing	A unique number to identify the provider who treated the recipient
Quantity of service	The number of units of service received by the recipient as shown on the claim record
Service code	The code used by the state to indicate the service provided (e.g., CPT, HCPCs)
Service code flag	A flag that identifies the coding system use for the service code
Service code modifier	A service code modifier to enhance the service code
Specialty code	Code which describes the area of specialty for the individual providing the service
Type of claim	A code indicating what kind of payment is covered in this claim (e.g., FFS, capitated payment, supplemental payment)
Type of service	A code indicating the type of service being billed
UB-92 revenue code	UB-92 revenue code reported on the UB-92 line item on the claim/encounter record

Source: MSIS Tape Specifications and Data Dictionary, Version 2 Release 5, last updated June 2006.

DRAFT 2 02/04/21 6:23 AM