Transformed - Medicaid Statistical Information System (T-MSIS)

The following pages contain detailed specifications for each data element (field) in the TMSIS ELIGIBLE file header record. In this section, the data elements are listed in alphabetical order.

For each data element, edit criteria are presented in the order in which they are applied during validation. All edits performed on monthly data elements are executed independently for each month in the reporting period. Unless stated otherwise, edits involving two or more monthly data elements always relate data for the same month.

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: DATE-FILE-CREATED

Definition: The date on which the file was created.

Field Description:

COBOL Example

PICTURE Value

9(8) 19870115

Coding Requirements: Required

Date format is CCYYMMDD (National Data Standard).

Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field.

Error Condition Resulting Error Code

1. Value is Non-Numeric .................................................................................................... 814

2. Value is not a valid date ................................................................................................. 102

3. Value is < End-of-Time-Period ....................................................................................... 501

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: END-OF-TIME-PERIOD

Description: Last date of the reporting period covered by the file to which this Header Record is

Attached

Field Description:

COBOL Example

PICTURE Value

9(08) 19871231

Coding Requirements:Required

Date format is CCYYMMDD (National Data Standard).

For ELIGIBLE File submissions, END-OF-TIME-PERIOD must always contain a month ending date (01/31, 3/31, and so on).

Example: The Tape Label Internal Dataset Name indicates that the reporting month is Month 1 of federal fiscal year 2008. The actual start and end dates of this month are January 1, 2008 and January 31, 2008 respectively.

It is essential that states assure that claims for days on or near the monthly fiscal cutoff date are counted in one and only one month.

Error Condition Resulting Error Code

1. Value is Non-Numeric ......................................................................................................................... 814

2. Value is not a valid date ..................................................................................................................... 102

3. Value is > DATE-FILE-CREATED ....................................................................................................... 501

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: FILE -NAME

Description: The name of the file to which this Header Record is attached. The name of the file also specifies the type of records contained in the file.

Field Description:

COBOL Example

PICTURE Value

X(08) CLAIMOT

Coding Requirements: Required

Valid Values Code Definition

ELIGIBLE Eligible File

CLAIMIP Inpatient Claim/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 1, 24, 25, or 39.

(Note: In CLAIMIP, TYPE-OF-SERVICE 24 and 25 refer only to services received on an inpatient basis.)

CLAIMLT Long Term Care Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 02, 04, 05 or 07 (all mental hospital, and NF services).

(Note: Individual services billed by a long-term care facility belong in this file regardless of service type.)

CLAIMOT Other Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 08 through 13, 15, 19 through 22, 24 through 26, 30, 31, 33 through 39. NEW TOS 51,52,53, or 54

CLAIMRX Pharmacy Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 16.

Error Condition Resulting Error Code

Value is not one of the allowable file names ................................................................................................ 201

listed above

Value is different from file name contained in the ...........................................................................................402

Tape Label Internal Dataset Name

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: FILE-STATUS-INDICATOR

Description: The test or production status of the file.

Field Description:

COBOL Example

PICTURE Value

X(01) P

Coding Requirements:

Valid Values Code Definition

P or T or Space Production File - ELIGIBLE Production Files must contain:

one record for each person who was eligible for Medicaid or CHIP during the reporting Month.
for each person who was granted retroactive eligibility during the reporting Month that covered a portion of a prior month one record must be included for each month covered and
records correcting prior month records that contained errors, if any.

CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX Production Files must contain:

one record of the appropriate claim/encounter type, for every separately adjudicated line item of every claim processed during the reporting month; and
one record for every adjustment to a prior month claim/encounter that was adjudicated during the reporting month.

Error Condition Resulting Error Code

Value is not “P” or Space ................................................................................................................ 201

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: SSN-INDICATOR

Definition: Indicates whether the state uses eligible' social security numbers (SSN) as MSIS-IDENTIFICATION-NUMBERs.

Field Description:

COBOL Example

PICTURE Value

X(01) 1

Coding Requirements:

Valid Values Code Definition

0 State does not use SSN as MSIS-IDENTIFICATION-NUMBER

1 State uses SSN as MSIS-IDENTIFICATION-NUMBER

The following is a detailed explanation on the use of this field in conjunction with the States' unique personal identification number.

Error Condition Resulting Error Code

Value is Non-Numeric ..................................................................................................................... 814

Value is < 0 OR Value is > 1 ........................................................................................................... 203

Unique Personal Identifiers

TMSIS identifies eligibles by means of a unique personal identification number that is assigned by the State. Some States use social security numbers as unique personal identification numbers. All other States create their own unique identification numbers according to some systematic scheme that is approved by CMS. Therefore, there are two alternatives for providing the personal Identification number to TMSIS (MSIS-ID). Those States using the SSN as the MSIS-ID are identified as SSN-States while those States that create the MSIS-ID are called Non-SSN States. A discussion of these alternatives, how the MSIS-ID should be provided to TMSIS, and the three inter-related fields used to provide this information follows. This discussion is provided at this time to afford a better understanding on the use of these interrelating fields and the use of the MSIS-ID in TMSIS. Additional information pertaining to the specific fields and their edit criteria will be found on the appropriate field definition pages.

All States must provide available SSNs on the eligible file, regardless of the use of this field as the unique MSIS identifier.

Non-SSN States will assign each eligible only one permanent MSIS-ID in his or her lifetime. When reporting eligibility records it is important that the SSN-INDICATOR in the Header record be set to 0 and the MSIS-ID for each record be provided in the MSIS-IDENTIFICATION-NUMBER field; if the MSIS-IDENTIFICATION-NUMBER is not known then this field should be filled with nines. The MSIS-ID identifies the individual and any claims submitted to the system.

- Provide the SSN in the SOCIAL-SECURITY-NUMBER field; if the SSN is not available the SOCIAL-SECURITY-NUMBER field should be filled with nines. Set the SSN-INDICATOR in the header record to 0. This setting indicates the manner in which the State assigns IDs for the validation program.

Once unique permanent personal identification numbers are assigned to eligibles, they must be consistently used to identify that individual, even if the individual is re-enrolled in a subsequent time period.

SSN States will use the SOCIAL-SECURITY-NUMBER field to provide the MSIS-ID when a permanent SSN is available for the individual. For these States the SSN-Indicator in the header record will be set to 1 and the MSIS-IDENTIFICATION-NUMBER in the eligible record should be blank.

- If the SSN is not available for an individual and the State has assigned a temporary identification number to the individual, the SOCIAL-SECURITY-NUMBER field should be left filled with eights and the temporary identification number should be provided in the MSIS-IDENTIFICATION-NUMBER field. When the individual is eventually assigned an SSN the State should report the SSN (now the individuals' ID) in the SOCIAL-SECURITY-NUMBER field and, for at least one (1) quarter, provide the temporary identification number in the MSIS-IDENTIFICATION-NUMBER field. This will enable CMS to establish a link between the SSN and the temporary identification number.

Four examples are provided concerning the rules for filling in the SSN-INDICATOR, SOCIAL-SECURITY-NUMBER, and MSIS-IDENTIFICATION-NUMBER fields:

(1) The State uses the SSN as an MSIS unique identifier AND the eligible had a valid SSN at the time eligibility was first established.

SSN-INDICATOR = 1

SOCIAL-SECURITY-NUMBER = Eligible's valid SSN

MSIS-IDENTIFICATION-NUMBER = Spaces

(2) The State uses the SSN as an MSIS unique identifier AND the eligible does not have a valid SSN (the State assigned a temporary ID).

SSN-INDICATOR = 1

SOCIAL-SECURITY-NUMBER = 888888888

MSIS-IDENTIFICATION-NUMBER = Temporary identification number assigned to Eligible

(3) The State uses the SSN as an MSIS unique identifier AND the eligible had previously been assigned a temporary ID, but has now been assigned a valid SSN.

SSN-INDICATOR = 1

SOCIAL-SECURITY-NUMBER = Eligible's valid SSN

MSIS-IDENTIFICATION-NUMBER = Temporary identification number assigned to Eligible (This should be carried for at least one quarter)

(4) The State does not use the SSN as an MSIS unique identifier AND the eligible has had the same, state-assigned, permanent identification number since eligibility was established.

SSN-INDICATOR = 0

SOCIAL-SECURITY-NUMBER = Eligible's valid SSN.

MSIS-IDENTIFICATION-NUMBER = State-assigned unique identifier

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: START-OF-TIME-PERIOD

Definition: Beginning date of the Month covered by this file.

Field Description:

COBOL Example

PICTURE Value

9(08) 19861001

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

For ELIGIBLE File submissions, START-OF-TIME-PERIOD must always contain a month starting date (1/1, 2/1, 3/1, and so on).

Example: The Tape Label Internal Dataset Name indicates that the reporting month is the Month 1 of federal fiscal year 1999. The actual start and end dates of this month are 1/1/1999 and 1/31/1999, respectively.

It is essential that states assure that claims for days on or near the monthly fiscal cutoff date are counted in one and only one month.

Error Condition Resulting Error Code

1. Value is Non-Numeric ............................................................................................................. 814

2. Value is not a valid date........................................................................................................... 102

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: STATE-ABBREVIATION

Definition: FIPS state alpha for each U.S. state, Territory, and the District of Columbia.

Field Description:

COBOL Example

PICTURE Value

X(02) ND

Coding Requirements:

Must be one of the following FIPS State abbreviations:

Error Condition Resulting Error Code

1. Value is not one of those listed above ............................................................................................................ 201

2. Value is different from State abbreviation contained in the Tape Label Internal Dataset Name ..................... 402

ELIGIBLE File - Data Field/Element Specifications

The following pages contain detailed specifications for each data element (field) MSIS ELIGIBLE file record. In this section, the data elements are listed in alphabetical order.

ELIGIBLE FILE – HEADER RECORD

Header Record Data Element Name: SEP-CHIP-PROGRAM-CODE-INDICATOR

Definition: SEP-CHIP-PROGRAM-CODE-INDICATOR This item applicable for separate child health programs only (Item is comparable to the program code field used in reporting the children enrolled in the separate children’s health insurance program on the SEDS form 21E). States should report enrollment data for each separate child health program and/or operational entity. The program code uniquely identifies the separate child health program to which the record pertains.

Field Description:

COBOL Example

PICTURE Value

X(07) FL1

Coding Requirements: Optional, when CHIP Code=3

The program code, should be a combination of the two-letter state abbreviation followed by descriptive letter or a number from 1 to 9. For example, the State of Florida would enter FL1 for children enrolled in its first separate child health program, FL2 for children enrolled in its second separate child health program, and so forth)

Error Condition Resulting Error Code

1. Value must be blank when CHIP-code <>’3’…………………………………………………….523

.ELIGIBLE FILE

Data Element Name: BASIS-OF-ELIGIBILITY

Definition: A code indicating the individual’s most recent Medicaid eligibility for the Month.

Field Description:

COBOL Example

PICTURE Value

X(01) 4

Coding Requirements:

Valid Values Code Definition

SEE ATTACHMENT 1 FOR DEFINITIONS OF MSIS CODING CATEGORIES

0 Individual was not eligible for Medicaid at any time during the month

1 Aged Individual

2 Blind/Disabled Individual

3 Not used

4 Child (not Child of Unemployed Adult, not Foster Care Child)

5 Adult (not based on unemployed status)

6 Child of Unemployed Adult (optional)

7 Unemployed Adult (optional)

Foster Care Child

A Individual covered under the Breast and Cervical Cancer Prevention and Treatment Act of 2000

9 Eligibility status Unknown (counts against error tolerance)

Submit records only for people who were eligible for Medicaid for at least one day during the FEDERAL-FISCAL-YEAR-MONTH. For people enrolled in non-Medicaid CHIP only for the month, enter ‘0’.

Error Condition Resulting Error Code

1. Value = ‘9’ 301

2. Value <> ‘0', ‘1, ‘2', ‘4', ‘5', ‘6', ‘7', ‘8', or 'A’ 203

3. Value = ‘8' AND MAINTENANCE- 503

ASSISTANCE-STATUS <> ‘4'

ELIGIBLE FILE

Data Element Name: BASIS-OF-ELIGIBILITY (continued)

Error Condition Resulting Error Code

4. (Value = ‘6' OR Value = ‘7') AND MAINTENANCE- 503

-ASSISTANCE-STATUS <> ‘1'

5. Value = 'A' AND MAINTENANCE- 503

-ASSISTANCE-STATUS <> '3'

6. Value = ‘1' AND DATE-OF-BIRTH implies Recipient 996

was NOT over 64 on the first day of the month

7. (Value = ‘4' OR Value = ‘6' OR Value = ‘8') AND DATE-OF-BIRTH implies Recipient 997

was NOT under 21 on the first day of the month

ELIGIBILITY FILE

Data Element Name: CERTIFIED-AMERICAN-INDIAN/ALASKAN-NATIVE-INDICATOR

Definition: Indicates that the individual is an American Indian or Alaskan Native whose race status is certified and therefore the state is eligible to receive 100% FFP

Field Description:

COBOL Example

PICTURE Value

9(01) 0

Coding Requirements:

Valid Values Code Definition

Not applicable
No, American Indian/Alaskan Native race status is not certified
Yes, American Indian/Alaskan Native race status is certified

Applicable but unknown

Error Condition Resulting Error Code

1. Value is not in the valid values list ???

2. Value is “9” 301

ELIGIBLE FILE

Data Element Name: CHIP-Code

Definition: A code indicating the individual’s inclusion in a STATE Only CHIP Program.

Field Description:

COBOL Example

PICTURE Value

9(01) “2”

Coding Requirements:

Valid Values Code Definition

0 Individual was not Medicaid eligible and not eligible for CHIP for the month

1 Individual was Medicaid eligible, but was not included in either Medicaid expansion CHIP (M-CHIP) OR a separate title XXI CHIP (State Only-CHIP) program for the month

2 Individual was included in the Medicaid expansion CHIP program (M-CHIP) and subject to enhanced Federal matching for the month

3 Individual was not Medicaid (M-CHIP) eligible, but was included in a non-Medicaid expansion title XXI CHIP (State Only-CHIP) program for the month.

4 Individual was both Medicaid eligible and XXI CHIP eligible during the same month

9 CHIP status unknown

Error Condition Resulting Error Code

1. Value = ‘9' 301

2. Value is not equal to ‘0', ‘1', ’2', ‘3’ or ‘4' 203

3. Value = ‘1’ or ‘2’ or ‘3’ and DAYS-OF-ELIGIBILITY = ‘0’ 502

ELIGIBLE FILE

Data Element Name: CITIZENSHIP-IND

Definition: Indicates if individual is identified as a U.S. Citizen.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric ………………………………………………………………………. 812

2. Value is ‘9'…………………………………………………………………………….……. 301

3 Value is not in list of valid values …………………………………………………….. 203

ELIGIBLE FILE

Data Element Name: DATE-OF-BIRTH

Definition: Individual’s Date of Birth

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Children enrolled in the Separate CHIP prenatal program option must not have a date of birth.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

ELIGIBLE FILE

Data Element Name: DATE-OF-DEATH

Definition: Individual's Date of Death

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If individual is deceased, and a complete, valid date is not available, set field = 99999999 (counts against error tolerance)

If individual is not deceased, set field = 88888888.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

4. Value is < DATE-OF-BIRTH or > (DATE-OF-BIRTH + 125 years) - 505

5. Value is > DATE-FILE-CREATED in Header Record - 501

ELIGIBLE FILE

Data Element Name: DAYS-OF-ELIGIBILITY

Definition: The number of days an individual was eligible for Medicaid during the month.

Please enter the sum of all days of all eligible cases for a person in a month in the DAYS-OF-ELIGIBILITY field, regardless of which MSIS-CASE-NUMs they have. (We understand this will cause a mis-match between DAYS-OF-ELIGIBILITY and MSIS-CASE-NUM).

Field Description:

COBOL Example

PICTURE Value

9(02) 30

Coding Requirements:

Valid values are 00 through the total number of days in the month referenced.

If invalid or missing, fill with 99.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value is 99 301

3. Value is < 00 OR Value is > number of days in the 203

month referred to.

ELIGIBLE FILE

Data Element Name: DISABILITY-STATUS-IND-1

Definition: Indicates if individual is deaf or has a serious difficulty hearing.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric - 812

2. Value is ‘9' 301

3. Value is not = ‘0’ or ‘1’ 203

ELIGIBLE FILE

Data Element Name: DISABILITY-STATUS-IND-2

Definition: Indicates if individual is blind or has serious difficulty seeing, even when wearing glasses.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric - 812

2. Value is ‘9' 301

3. Value is not = ‘0’ or ‘1’ 203

ELIGIBLE FILE

Data Element Name: DISABILITY-STATUS-IND-3

Definition: Indicates if individual has serious difficulty concentrating because of a physical, mental or emotional condition (5 years or older).

Field Description:

COBOL Example

PICTURE Value

901) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric - 812

2. Value is ‘9' 301

3. Value is not = ‘0’ or ‘1’ 203

ELIGIBLE FILE

Data Element Name: DISABILITY-STATUS-IND-4

Definition: Indicates if individual has serious difficulty walking or climbing stairs(5 years or older).

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric - 812

2. Value is ‘9' 301

3. Value is not = ‘0’ or ‘1’ 203

ELIGIBLE FILE

Data Element Name: DISABILITY-STATUS-IND-5

Definition: Indicates if individual has serious difficulty dressing or bathing(5 years or older).

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric - 812

2. Value is ‘9' 301

3. Value is not = ‘0’ or ‘1’ 203

ELIGIBLE FILE

Data Element Name: DISABILITY-STATUS-IND-6

Definition: Indicates if individual has difficulty doing errands alone such as visiting a doctor’s office or shopping because of a physical, mental or emotional condition (15 years or older).

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric - 812

2. Value is ‘9' 301

3. Value is not = ‘0’ or ‘1’ 203

ELIGIBLE FILE

Data Element Name: DUAL-ELIGIBLE-CODE

Definition: Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits.

Field Description:

COBOL Example

PICTURE Value

9(02) 00

Coding Requirements:

Valid Values Code Definition

00 Individual is not a Medicare beneficiary

01 Individual is entitled to Medicare- QMB only

Individual is entitled to Medicare- QMB AND Medicaid coverage including RX

03 Individual is entitled to Medicare- SLMB only

04 Individual is entitled to Medicare- SLMB AND Medicaid coverage including RX

05 Individual is entitled to Medicare- QDWI

06 Individual is entitled to Medicare- Qualifying individuals

08 Individual is entitled to Medicare- Other Dual Eligibles (Non QMB, SLMB,QWDI or QI) with Medicaid coverage including RX

09 Other Dual Eligible's - This code is to be used only with specific CMS approval.

10 Separate CHIP (S-CHIP) Individual is entitled to Medicare

00. Individual Is Not a Medicare Beneficiary - The individual is not entitled to Medicare coverage.

Medicare Dual Eligibles - The following describes the various categories of individuals who, collectively, are known as dual eligible. Medicare has two basic coverage’s: Part A, which pays for hospitalization costs; and Part B, which pays for physician services, lab and x‑ray services, durable medical equipment, and outpatient and other services. Dual eligible are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit.

01. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) ‑ These individuals are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare deductibles and coinsurance for Medicare services provided by Medicare providers.

02. QMBs with Medicaid Coverage (QMB Plus). These individuals are entitled to Medicare Part A, have income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility. Through 2005, individuals in this group qualify for one or more Medicaid benefits including prescription drug coverage. Effective 2006, they qualify for one or more Medicaid benefits that do not include prescription drugs. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare deductibles and coinsurance, and provides one or more Medicaid benefits. QMB individuals with prescription drug coverage are included in this group through December 2005.

Beginning in January 2006, Part D provides drug coverage for these individuals, and Medicaid drug benefits are not required for an individual to be reported in this group.

03. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) – These individuals are entitled to Medicare Part A, have income of 100 ‑120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.

04. SLMBs with Medicaid Coverage (SLMB Plus). These individuals are entitled to Medicare Part A, have income of 100-120% FPL and resources that do not exceed twice the limit for SSI eligibility. Individuals in this group qualify for one or more Medicaid benefits excluding prescription drug coverage benefits. Medicaid pays their Medicare Part B premiums and provides one or more Medicaid benefits.

05. Qualified Disabled and Working Individuals (QDWIs) ‑ These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only.

06. Qualifying Individuals (QIs) ‑ There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of 120 ‑135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only with 100% Federal funding.

08. Other Dual Eligibles with Medicaid Coverage (Non QMB, SLMB, QDWI or QI) - These individuals are entitled to Medicare Part A and/or Part B and are eligible for one or more Medicaid benefits. They are not eligible for Medicaid as a QMB, SLMB, QDWI or QI. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid poverty group that exceeds the limits listed above. Medicaid pays for Medicaid services provided by Medicaid providers, but only to the extent that the Medicaid rate exceeds any Medicare payment for services covered by both Medicare and Medicaid. Payment by Medicaid of Part B premiums is a state option.

09. Other Dual Eligibles (e.g., Pharmacy + Waivers; states not including prescription drugs in Medicaid benefits for some groups) – Special dual eligible groups not included above, but approved under special circumstances. This code is to be used only with specific CMS approval.

10. S-CHIP Eligibles – These individuals are entitled to Medicare Part A and/or Part B and are eligible for S-CHIP benefits.

Error Condition Resulting Error Code

1. Value is Non-Numeric ………………………………………………………….……. 812

2. Value is 99……………………………………………………………………………………….………… 301

3. Value is < 00 OR Value = 07 OR Value is > 10 AND < 99 …………………………………………….. 203

4. If Value = {01, 03, 05, OR 06} AND MAINTENANCE-ASSISTANCE-STATUS <>”3"……………. 503

ELIGIBLE FILE

Data Element Name: ELIGIBLE-ADDR-BEGIN-DATE

Definition: The date on which the individual moved to the listed address.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If date is not known, fill with 99999999.

Fill with 99999999 if not a new address.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 301

3. Value is not a valid date 102

4. Value > END-OF-TIME-PERIOD in the Header Record 605

ELIGIBLE FILE

Data Element Name: ELIGIBLE-ADDR-LN1 - ELIGIBLE-ADDR-LN3

Definition: The street address(es) of where the individual eligible to receive healthcare services resides.

Field Description:

COBOL Example

PICTURE Value

X(28) “123, Any Lane”

Coding Requirements: Required

Line 1 is required and the other two lines can be blank.

Enter last known street address(es) for the month.

Error Condition Resulting Error Code

1. Value is “Space Filled” 303

ELIGIBLE FILE

Data Element Name: ELIGIBLE-CITY

Definition: The city where the individual eligible to receive healthcare services resides.

Field Description:

COBOL Example

PICTURE Value

X(28) “Baltimore”

Coding Requirements: Required

Enter last known city for the month.

Error Condition Resulting Error Code

1. Value is “Space Filled” 303

ELIGIBLE FILE

Data Element Name: ELIGIBLE-COUNTY-CODE

Definition: FIPS county code indicating the county of residence of where the individual eligible to receive healthcare services resides.

Field Description:

COBOL Example

PICTURE Value

9(03) 037

Coding Requirements:

Use the National Bureau of Standards, Federal Information Processing Standards (FIPS) numeric county codes for each State.

Value = 000 if the eligible resides out-of-State.

If code is missing or code is unavailable, 9-fill.

Enter last known code for the month.

Source: http://www.itl.nist.gov/fipspubs/co-codes/states.htm

Error Condition Resulting Error Code

1. Value is Non-Numeric 812

2. Value is 999 301

3. Value is not a valid county code for this State 201

AND Value <> 000

ELIGIBLE FILE

Data Element Name: ELIGIBLE-COUNTY-NAME

Definition: The county where the individual eligible to receive healthcare services resides.

Field Description:

COBOL Example

PICTURE Value

X(28) “Baltimore”

Coding Requirements: Required

County name as it appears in the state system.

Enter last known county name for the month.

Source: http://www.itl.nist.gov/fipspubs/co-codes/states.htm

Error Condition Resulting Error Code

1. Value is “Space Filled” 303

ELIGIBLE FILE

Data Element Name: ELIGIBLE-FIRST-NAME

Definition: The first name of the individual eligible to receive health care services.

Field Description:

COBOL Example

PICTURE Value

X(12) “Mickey”

Coding Requirements: Conditional.

Error Condition Resulting Error Code

1. Value is “Space Filled” 303

ELIGIBLE FILE

Data Element Name: ELIGIBLE-LAST-NAME

Definition: The last name of the individual eligible to receive healthcare services.

Field Description:

COBOL Example

PICTURE Value

X(28) Jones

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is “Space Filled” 303

ELIGIBLE FILE

Data Element Name: ELIGIBLE-MIDDLE-INIT

Definition: The middle initial of the individual eligible to receive healthcare services.

Field Description:

COBOL Example

PICTURE Value

X(01) R

Coding Requirements:

Leave blank if not available

Error Condition Resulting Error Code

1. Value is not an alphabetic character, or a blank (A-Z, a-z, ) ???

ELIGIBLE FILE

Data Element Name: ELIGIBLE-PHONE-NUM

Definition: The telephone number of the individual eligible to receive healthcare services.

Field Description:

COBOL Example

PICTURE Value

X(10) “0123456789”

Coding Requirements: Required

If unknown, 9-fill.

Enter last known phone number for the month.

Enter digits only (i.e., no parentheses, dashes, periods, commas, spaces, etc.)

Error Condition Resulting Error Code

1. Value = "9 filled if unknown" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

ELIGIBLE FILE

Data Element Name: ELIGIBLE-STATE

Definition: The FIPS state alpha for the U.S. state, Territory, or the District of Columbia code for where the individual eligible to receive healthcare services resides.

Field Description:

COBOL Example

PICTURE Value

X(02) “MD”

Coding Requirements: Required

Enter last known state for the month. Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1 Value is not in the list of valid values ……………………………………………………………………. ???

1. Value is “Space Filled” 303

2. Value = "9 filled if unknown" 301

ELIGIBLE FILE

Data Element Name: ELIGIBLE-ZIP-CODE

Definition: The Zip code where the individual eligible to receive healthcare services resides.

Field Description:

COBOL Example

PICTURE Value

9(09) 210300000

Coding Requirements: Required

Redefined as 9(05) and 9(04)

9(05) is needed If value is unknown fill with 99999

9(04) could be zero filled

Enter last known zip code for the month.

Error Condition Resulting Error Code

1. Value is not numeric 812

2. Value = "999999999" 301

3. Value is “Space Filled” 303

4. Value is 0-filled 304

ELIGIBLE FILE

Data Element Name: ELIGIBILITY-GROUP

Definition: A newly created set of detailed Eligibility codes which will be utilized for the new populations entering the state eligibility systems as well as describing existing populations and former eligibility groups. Many of these categories can be mapped to current MASBOE definitions (not applicable for future eligibility groups). This code set will be utilized in MACPRO.

A set of 60 codes is attached for an initial roll out (Additional values will be added to this field.)

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements: Required

Valid Values 01 – 60. Code Definition

Please see ATTACHMENT 4 – New Eligibility Group Table

ELIGIBLE FILE

Data Element Name: ELIGIBILITY-STATUS

Definition: The Medicaid or CHIP eligibility status of an individual. A status of terminated or suspended means an individual is no longer receiving any Medicaid or CHIP benefits.

Field Description:

COBOL EXAMPLE

PICTURE VALUE

9(02) 01

Valid Values Code Definition

01 Eligible for Medicaid

02 Eligible for CHIP

03 Suspended from Medicaid and CHIP (e.g., for incarceration)

04 Terminated from Medicaid and CHIP (e.g. for fraud)

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

ELIGIBLE FILE

Data Element Name: ELIGIBILITY-STATUS-CHANGE-REASON

Definition: The reason for a change in an individual's eligibility status. Report this reason when there is a change in the individual's eligibility status within the reporting month.

Field Description:

COBOL EXAMPLE

PICTURE VALUE

9(02) 01

Valid Values Code Definition

01 Excess income

02 Excess assets

03 Income reduced (eligibility changed from CHIP to Medicaid)

04 Aged out of program

05 No longer in the foster care system

06 Death

07 No longer disabled

08 No longer institutionalized

09 No longer in need of long-term care services resides

10 Obtained employer sponsored insurance

11 Gained access to public employees health plan

12 Obtained other coverage (not ESI or pubic employees health plan)

13 Failure to respond

14 Failure to pay premium or enrollment fees

15 Moved to a different state

16 Voluntary request for termination

17 Lack of verifications

18 Fraud

19 Suspension due to incarceration

20 Other

Error Condition Resulting Error Code

1. The value entered is not in the valid values list ???

ELIGIBILITY FILE

Data Element Name: ELIGIBILITY-STATUS-EFFECTIVE-DATE

Definition: The start date of a individual's reported Eligibility Status.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If it is unknown when eligibility status began, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

ELIGIBILE FILE

Data Element Name: ELIGIBILITY-STATUS-END-DATE

Definition: The date that an individual's reported Eligibility Status ended.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If it is unknown when eligibility status ended, enter all 9s.

Error Condition Resulting Error Code

1 Value is Non-Numeric ………………………………………………………………….…………….. 810

2 Value = 99999999 ……………………………………………………………………………….…… 301

Value is not a valid date ………………………………………………………………...………….. 102

ELIGIBLE FILE

Data Element Name: ETHNICITY-CODE 1 - 4

Definition: A code indicating that the eligible has indicated an ethnicity of Hispanic, Latino/a, or Spanish origin.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Use this code to indicate if the eligible’s demographics include an ethnicity of Hispanic or Latino.

This determination is independent of indication of RACE-CODE .

Valid Values Code Definition

0 Not of Hispanic or, Latino/a, or Spanish origin

1 Mexican, Mexican American, Chicano/a

2 Puerto Rican

3 Cuban

4 Another Hispanic, Latino, or Spanish origin

9 Ethnicity Unknown

Error Condition: Resulting Error Code

1 Value is not in the list of valid values ……………………………………………………………………….. ???

2 Value is 9-filled ………………………………………………………………………………………………… 301

ELIGIBLE FILE

Data Element Name: FEDERAL-FISCAL-YEAR-MONTH

Definition: Indicates the Federal Fiscal Year and Month for the record.

Field Description:

COBOL Example

PICTURE Value

9(06) 200101

Coding Requirements: Required

Values conform to the format “CCYYMM”, where CCYY is the Federal Fiscal Year covered by this Eligibility Record (e.g. “2001” for FFY 2001) and MM is the Federal Fiscal Month covered by this Eligibility Record (where MM is defined as October being month 01 and September being month 12).e.g., October is “01”).

Error Condition Resulting Error Code

1. Value is not numeric 812

2. MM < 01 or MM > 12 203

3. CCYY is < 1984 203

4. Value is > than the fiscal month specified in END-OF-TIME-PERIOD 506

in Header-Record

5. Value is < than the fiscal month specified by START-OF-TIME-PERIOD 506

in Header-Record AND TYPE-OF-RECORD = 1

6. Value is = fiscal month specified by START-OF-TIME-PERIOD 506

in Header-Record AND TYPE-OF-RECORD = {2,3}

ELIGIBILE FILE

Data Element Name: HEALTH-HOME-CHRONIC-CONDITION (1-4)

Definition: The chronic condition used to determine the individual's eligibility for the health home provision.

Note that the list of chronic conditions for eligibility in the health home program is a subset of all chronic conditions.

Examples of chronic conditions specifically identified in ACA Section 2703 are listed below and serve as the basis for the valid values list. The term “chronic condition” has the meaning given that term by the Secretary and shall include, but is not limited to, the following:

(A) A mental health condition.

(B) Substance use disorder.

(D) Diabetes.

(E) Heart disease.

(F) Being overweight, as evidenced by having a Body Mass Index (BMI) over 25.

ACA Section 2703 can be viewed at this hyperlink: (http://www.ssa.gov/OP_Home/ssact/title19/1945.htm#ftn490 )

Field Description:

COBOL Example

PICTURE Value

X(01) F

Coding Requirements:

Valid Values Code Definition

A Mental health

B Substance abuse

C Asthma

D Diabetes

E Heart disease

F Overweight (BMI of >25)

G HIV/AIDS

H Other

If value H (Other) is selected, identify the chronic condition in HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION (1-4).

Error Condition Resulting Error Code

1 Value is not in the list of valid values …………………………………………………………………. ???

2 Value is “9” ………………………………………………………………………………………………. 301

ELIGIBILITY FILE

Data Element Name: HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION (1-4)

Definition: A free-text field to capture the description of the other chronic condition (or conditions) when value “H” (Other) appears in the HEALTH-HOME-CHRONIC-CONDITION (1-4)

Field Description:

COBOL Example

PICTURE Value

X(50) RA/OA (Rheumatoid Arthritis/ Osteoarthritis)

Coding Requirements:

Conditional (required when value “H” (Other) appears in HEALTH-HOME-CHRONIC-CONDITION (1-4)

The iteration number (i.e., 1 through 4) should correspond with the iteration number of the associated value in the HEALTH-HOME-CHRONIC-CONDITION (1-4) field.

Limit characters to alphabet (A-Z, a-z), numerals (0-9), parentheses (()), forward slash (/), dashes (-), periods (.), commas (,)

Error Condition Resulting Error Code

1 Value contains invalid characters ……..………………………………………………………………. ???

2 Field is blank when HEALTH-HOME-CHRONIC-CONDITION (1-4) = H ………………...………. 301

2 Field is populated when HEALTH-HOME-CHRONIC-CONDITION (1-4) <> H ……….....………. 301

ELIGIBLE FILE

Data Element Name: HEALTH-HOME-IND

Definition: A flag indicating an individual receiving coordinated care through a Health Home. (ACA Section 2703, for Medicaid beneficiaries with a chronic disease condition(s)).

Field Description:

COBOL Example

PICTURE Value

9(01) “1”

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not in valid values list ???

2. Value is ‘9' 301

ELIGIBILE FILE

Data Element Name: HEALTH-HOME-PROV-NPI-NUM (1-4)

Definition: The NPI of the individual’s primary care manager for the Health Home in which the individual is enrolled.

Field Description:

COBOL Example

PICTURE Value

X(10) “1234567890”

Coding Requirements: Required.

If legacy identifiers are available for providers, then report the legacy IDs in the HEALTH-HOME-PROV-NUM field and the NPIs in this field. If only the legacy IDs are available, then 9-fill this field and enter the legacy IDs in the HEALTH-HOME-PROV-NUM fields.

If value is not applicable, 8-fill the field.

If value is applicable but unknown, fill with "9999999999".

Error Condition Resulting Error Code

1. Value = "9999999999" 301

2. Value is “Space-filled” 303

3. Value is 0-filled 304

ELIGIBILITY FILE

Data Element Name: HEALTH-HOME-PROV-NUM (1-4)

Definition: A unique identification number assigned by the state to the individual’s primary care manager for the Health Home in which the individual is enrolled.

Field Description:

COBOL Example

PICTURE Value

X(12) “01CA79300000”

Coding Requirements: Required

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

If Value is unknown, fill with "999999999999".

Note: Once a national provider ID numbering system is in place, the national number should be used.

If the State’s legacy ID number is also available then that number can be entered in this field.

Error Condition Resulting Error Code

1. Value is 9-filled …………………………………………………………………………………………….. 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

ELIGIBILITY FILE

Data Element Name: HEALTH-HOME-SPA-ID (1-4)

Definition: A free-form text field for the CMS assigned unique identification number for the Health Home SPA that the individual is participating in.

Field Description:

COBOL Example

PICTURE Value

X(100) Coordinated Care Associates, LLC.

Coding Requirements:

The HEALTH-HOME-SPA-ID field must be populated whenever the HEALTH-HOME-PROVIDER-IND on the claim header record is set to “Yes.”

Valid characters in the text string are limited to alpha characters (A-Z, a-z), numbers (0-9), dashes (“-“), commas (“,”), forward slashes (/), and periods (“.”).

Error Condition Resulting Error Code

1. The HEALTH-HOME-ENTITY-NAME field is empty even though the HEALTH-HOME-PROVIDER-IND field is set to “Yes.” ???

2. The text string contains invalid characters ???

ELIGIBILITY FILE

Data Element Name: HEALTH-HOME-SPA-START-DATE (1-4)

Definition: The date the State Plan Option for this Health Home went into effect in the state.

Field Description:

COBOL Example

PICTURE Value

9(08) 20121001

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If the effective date is unknown, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value is empty even though there is a corresponding HEALTH-HOME-SPA-ID (1-4) value - ???

ELIGIBILITY FILE

Data Element Name: HEALTH-HOME-START-DATE (1-4)

Definition: The date on which the individual’s participation in the Health Home started.

Field Description:

COBOL Example

PICTURE Value

9(08) 20120101

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If the effective date is unknown, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value is empty even though there is a corresponding HEALTH-HOME-SPA-ID (1-4) value - ???

ELIGIBLE FILE

Data Element Name: HEALTH-INSURANCE-IND

Definition: A flag indicating whether the individual had private health insurance coverage during the month. This includes coverage purchased by the State or by a third party. Medicare is not considered private health insurance. Enrollment in a Medicaid/Medicare HMO does not constitute health insurance for this data element.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 Not eligible for Medicaid during month

1 Individual did not have private insurance coverage

2 Individual had private health insurance coverage purchased by a third party

3 Individual had private health insurance coverage purchased by the State

4 Individual had private health insurance but funding source unknown

9 State had only invalid or missing information

Error Condition Resulting Error Code

1. Value is not in valid values list ???

2. Value is 9-filled 301

ELIGIBILE FILE

Data Element Name: HOUSEHOLD-SIZE

Definition: Household Size used in the eligibility determination process will include values ranging from (1) to (8 or more).

Field Description:

COBOL Example

PICTURE Value

X(03) “08+”

Coding Requirements: Required.

Valid Values Code Definition

001 1 person

002 2 people

003 3 people

004 4 people

005 5 people

006 6 people

007 7 people

08+ 8 or more people

999 Unknown number of people

Error Condition Resulting Error Code

1 Value is not in the list of valid values ???

2 Value is 9-filled …………………………………………………………………………………..………… 301

ELIGIBLE FILE

Data Element Name: IMMIGRATION-STATUS

Field Description:

COBOL Example

PICTURE Value

9(01) 2

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable (U.S. Citizen) enter all 8s.

If it is unknown when the person’s 5 year eligibility restriction ends, enter all 9s.

Valid Values Code Definition

0 Not Applicable (U.S. citizen)

1 Qualified non-citizen

2 Lawfully present under CHIPRA 214

3 Eligible only for payment for emergency services

9 Unknown

Error Condition Resulting Error Code

1 Value is not in the list of valid values ???

2 Value is 9-filled …………………………………………………………………………………..………… 301

ELIGIBILE FILE

Data Element Name: IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE

Definition: Indicates the last day of the immigration status five-year bar for an individual.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable (U.S. Citizen) enter all 8s.

If it is unknown when the person’s 5 year eligibility restriction ends, enter all 9s.

Error Condition Resulting Error Code

1 Value is not numeric 812

2 Value is invalid date 810

3 Value is 9-filled 301

ELIGIBLE FILE

Data Element Name: INCOME-CODE

Definition: A code indicating the family income level for the month.

Field Description:

COBOL Example

PICTURE Value

X(02) “00”

Coding Requirements:

Valid Values Code Definition

BLANK State has not opted to include this field for ANY Eligible-file records

00 Individual was not a Medicaid eligible and not eligible for CHIP for the month

01 Individual’s family income is from 0 to 100% of the FPL for the month

02 Individual’s family income is from 101 to 200% of the FPL for the month

03 Individual’s family income is from 201 to 250% of the FPL for the month

04 Individual’s family income is from 251 to 300% of the FPL for the month

05 Individual’s family income is over 300% of the FPL for the month

88 Individual was eligible for Medicaid, but above the age limit for CHIP enrollment

99 Individual’s State-defined family income is UNKNOWN for the month

Error Condition Resulting Error Code

1. Value is not in valid values list 301

2. Value = ‘99’ 301

ELIGIBILE FILE

Data Element Name: LEVEL-OF-CARE-STATUS

Definition: The kind of care required to meet an individual's needs and used to determine program eligibility.

Field Description:

COBOL Example

PICTURE Value

X(03) “001”

Coding Requirements: Required.

Valid Values Code Definition

001 Hospital as defined in 42 CFR §440.10

002 Inpatient psychiatric facility for individuals under age 21 as provided in 42 CFR § 440.160

003 Nursing Facility

004 ICF/IDD

005 Other Type of Facility

999 Unknown

Error Condition Resulting Error Code

1. Value = "9-filled" 301

2. Value is not in the valid values list ???

ELIGIBLE FILE

Data Element Name: LOCKIN-BEGIN-DATE1 - LOCKIN-BEGIN-DATE12

Definition: The date on which the lock in period begins for an individual with a healthcare service/ provider.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 9-filled 301

3. Value is not a valid date 102

ELIGIBLE FILE

Data Element Name: LOCKIN-END-DATE1 - LOCKIN-END-DATE12

Definition: The date on which the lock in period ends for an individual with a healthcare service/ provider.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

ELIGIBLE FILE

Data Element Name: LOCKIN-PROV-NPI-NUM1 - LOCKIN-PROV-NPI-NUM12

Definition: The National Provider ID (NPI) of the provider furnishing locked-in healthcare services to an individual.

Field Description:

COBOL Example

PICTURE Value

X(10) “013679300000”

Coding Requirements: Required

Record the value exactly as it appears in the State system.

If legacy identifiers are available for providers, then report the legacy IDs in the LOCKIN-PROV-NUM field and the NPI in this field. If only the legacy Provider ID is available, then 9-fill this field and enter the legacy IDs in the LOCKIN-PROV-NUM fields.

If Value is unknown, fill with "999999999999".

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

ELIGIBLE FILE

Data Element Name: LOCKIN-PROV-NUM1 - LOCKIN-PROV-NUM12

Definition: A unique identification number assigned by the state to a provider furnishing locked-in healthcare services to an individual.

Field Description:

COBOL Example

PICTURE Value

X(12) “01CA79300000”

Coding Requirements: Required

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

If Value is unknown, fill with "999999999999".

Note: Once a national provider ID numbering system is in place, the national number should be used.

If the State’s legacy ID number is also available then that number can be entered in this field.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

ELIGIBLE FILE

Data Element Name: LTC-ELIGIBILITY-BEGIN-DATE (1 – 4)

Definition: The date on which the individual’s eligibility to long term care nursing home service began. (This field should use the onset date of the eligibility period and not the service span.)

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

ELIGIBLE FILE

Data Element Name: LTC-ELIG-IND (1 – 4)

Definition: - A flag indicating the individual’s eligibility to long term care nursing home privileges.

Field Description:

COBOL Example

PICTURE Value

9(01) “1”

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric 812

2. Value is ‘9’ 301

3. Value is not = ‘0’, ‘1’, or ‘9’ 203

ELIGIBLE FILE

Data Element Name: LTC-ELIGIBILITY-END-DATE (1 – 4)

Definition: The date on which the individual’s eligibility to long term care nursing home service ended. (This field should use the end date of the eligibility period and not the service span.)

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

ELIGIBLE FILE

Data Element Name: LTC-LEVEL-CARE (1 –4)

Definition: - The level of care provided to the individual by the long term care facility.

Field Description:

COBOL Example

PICTURE Value

9(01) “1”

Coding Requirements:

Valid Values Code Definition

Skilled care.

Skilled care is nursing and rehabilitative care that is prescribed by a physician and is delivered on a daily basis by skilled medical personnel such as nurses or therapists. Skilled care is generally provided to assist patients during recovery following hospitalization for treatment of acute conditions

Intermediate care

Intermediate care is provided intermittently, or periodically, for patients who are recovering from acute conditions but do not need continuous care or daily therapeutic services. Intermediate care is provided by skilled professionals such as registered or licensed practical nurses, and therapists, under the supervision of a physician.

Custodial care

Custodial care provides assistance to patients in daily activities such as bathing, dressing, toileting, and eating. Custodial care is often needed as a result of chronic illnesses that decrease an individual's ability to remain independent. While custodial care must be supervised by a physician, not all custodial care must be delivered by skilled professionals and is frequently provided by nurse's aides.

Unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value is ‘9’ 301

ELIGIBLE FILE

Data Element Name: LTC-PROV-NPI-NUM (1 – 4)

Definition: The National Provider ID (NPI) of the long term care facility furnishing healthcare services to the individual.

Field Description:

COBOL Example

PICTURE Value

X(10) “013679300000”

Coding Requirements: Required

If legacy identifiers are available for providers, then report the legacy IDs in the Provider ID field and the NPI in this field. If only the legacy Provider ID is available, then 9-fill the National Provider ID and enter the legacy IDs in the Provider ID fields.

If value is unknown, 9-fill.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4 Value is not in the list of valid NPIs ……………………………………………………………………… ???

ELIGIBLE FILE

Data Element Name: LTC-PROV-NUM (1 – 4)

Definition: A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual.

Field Description:

COBOL Example

PICTURE Value

X(12) 10) “01CA79300000”

Coding Requirements: Required

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

If Value is unknown, fill with "999999999999".

Note: Once a national provider ID numbering system is in place, the national number should be used.

If the State’s legacy ID number is also available then that number can be entered in this field.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

ELIGIBLE FILE

Data Element Name: MAINTENANCE-ASSISTANCE-STATUS

Definition: A code indicating the individual’s maintenance assistance status. See Attachment 1 for a description of MSIS coding categories.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 Individual was not eligible for Medicaid this month

1 Receiving Cash or eligible under section 1931 of the Act

2 Medically Needy

3 Poverty Related

4 Other

5 1115 - Demonstration expansion eligible

9 Status is unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is ‘9’ 301

3. Value is = ‘1’, ‘2’, ‘3’, ‘4’, or ‘5’ in any month later than the month that included the date of death 504

ELIGIBILITY FILE

Data Element Name: MANAGED-CARE-PLAN-ENROLLMENT-END-DATES (1-4)

Definition: The date an individual's enrollment in a managed care plan ends. Each instance corresponds to a Plan Id in MANAGED-CARE-PLAN-ID1 thru 4.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If it is unknown when the person’s enrollment in the managed care plan ends, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value is empty even though there is a corresponding MANAGED-CARE-PLAN-ID1 thru 4 value - ???

ELIGIBILITY FILE

Data Element Name: MANAGED-CARE-PLAN-ENROLLMENT-START-DATES (1-4)

Definition: The effective date of an individual's enrollment in a managed care plan. Each instance corresponds to a Plan Id.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

If not applicable enter all 8s.

If it is unknown when the person’s enrollment in the managed care plan starts, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value is empty even though there is a corresponding MANAGED-CARE-PLAN-ID1 - 4 value ???

ELIGIBLE FILE

Data Element Name: MANAGED-CARE-PLAN-ID (1 – 4)

Definition: The managed care plan identification number under which the eligible individual is covered. States can specify up to four managed care plan identification numbers

Use the state’s own identifier. If the state uses the national health plan identifier as itititits internal number, enter that value in this field as well as the NATIONAL-HEALTH-PLAN-IDENTIFIER field.

Field Description:

COBOL Example

PICTURE Value

X(12) MED001356

Coding Requirements:

Please fill in the MANAGED-CARE-PLAN-ID in sequence (e.g., if an individual is enrolled in two managed care plans, only the first and second fields should be used; if only enrolled in one managed care plan, code MANAGED-CARE-PLAN-ID1 and 8-fill MANAGED-CARE-PLAN-ID2 through MANAGED-CARE-PLAN-ID4).

Enter the managed care plan identification number assigned by the State.

If individual is not enrolled in any managed care plan 8-fill all four fields.

Error Condition Resulting Error Code

1. Value is space-filled 303

2. Value is = ‘888888888888’ and corresponding 538

MANAGED-CARE-PLAN-TYPE >= 01 and <=08

3. Value is <> ‘888888888888’ and corresponding MANAGED-CARE-PLAN-TYPE = 00 538

4. Value appears more than once and value <> ‘888888888888’ 532

ELIGIBLE FILE

Data Element Name: MANAGED-CARE-PLAN-TYPE (1 – 4)

Definition: Codes for specifying up to four managed care plan types under which the eligible individual is enrolled.

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements: Required.

Please fill in the MANAGED-CARE-PLAN-TYPE in sequence (e.g., if an individual is enrolled in two managed care plans, only the first and second fields should be used; if only enrolled in one managed care plan, code MANAGED-CARE-PLAN-TYPE1 and 8-fill MANAGED-CARE-PLAN-TYPE2 through MANAGED-CARE-PLAN-TYPE4).

Values must correspond to associated MANAGE-CARE-PLAN-ID.

Valid Values Code Definition

00 Not applicable, individual is eligible for Medicaid or CHIP but not enrolled in a managed care plan

01 Individual is enrolled in a Comprehensive MCO

02 Individual is enrolled in a Traditional PCCM Provider arrangement

03 Individual is enrolled in an Enhanced PCCM Provider arrangement

04 Individual is enrolled in a HIO

05 Individual is enrolled in a Medical-only PIHP (risk or non-risk/non-comprehensive/with inpatient hospital or institutional services)

06 Individual is enrolled in a Medical-only PAHP (risk or non-risk/non-comprehensive/no inpatient hospital or institutional services)

07 Individual is enrolled a Long Term Care (LTC) PIHP

08 Individual is enrolled a Mental Health (MH) PIHP

09 Individual is enrolled in a Mental Health (MH) PAHP

10 Individual is enrolled in a Substance Use Disorders (SUD) PIHP

11 Individual is enrolled in a Substance Use Disorders (SUD) PAHP

12 Individual is enrolled in a Mental Health (MH) and Substance Use Disorders (SUD) PIHP

13 Individual is enrolled in a Mental Health (MH) and Substance Use Disorders (SUD) PAHP

14 Individual is enrolled in a Dental PAHP

15 Individual is enrolled in a Transportation PAHP

16 Individual is enrolled in a Disease Management PAHP

17 Individual is enrolled in Program for All-Inclusive Care for the Elderly (PACE)

99 Individual’s managed care plan status is unknown

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is not in the valid values list ???

ELIGIBLE FILE

Data Element Name: MARITAL-STATUS

Definition: Identification of an individual's marital status.

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements: Required.

Valid Values Code Definition

01 Never married

02 Married, spouse present

03 Married, spouse absent

04 Legally separated

05 Divorced

06 Widower/Widow

07 Other

99 Unknown

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is not in the valid values list ???

ELIGIBLE FILE

Data Element Name: MEDICARE-HIC-NUM

Definition: The individual’s Medicare Health Insurance Claim (HIC) Identification Number, if applicable.

Field Description:

COBOL Example

PICTURE Value

X(12) “00123456789A”

Coding Requirements:

If individual is enrolled in Medicare and HIC Number is not available, 9-fill field.

If individual is NOT enrolled in Medicare, 8-fill field.

Error Condition Resulting Error Code

1. Value is improperly “Space Filled” 303

2. Value is 9-filled 301

3. Value is 0-filled 304

4. Value is 8-filled AND DUAL-ELIGIBLE-FLAG = {01,02,03,04,05,06,07,08, 09, or 10} 537

ELIGIBLE FILE

Data Element Name: MFP-ENROLLMENT-START-DATE (1- 2)

Definition: The date on which the individual’s participation in the Money Follows the Person Demonstration started.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete valid date is unknown, 9-fill.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 9-filled 301

3. Value is not a valid date 102

ELIGIBLE FILE

Data Element Name: MFP-ENROLLMENT-END-DATE (1 – 4)

Definition: The date on which the individual’s participation in the Money Follows the Person Demonstration ended.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete valid date is unknown, 9- fill.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

Data Element Name: MFP-REASON-PARTICIPATION-ENDED (1 -2)

Definition: A code describing reason why individual’s participation in the Money Follows the Person Demonstration ended

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements:

Valid Values Code Definition

00 Default – No Participation

01 Completed 365 days of participation

02 Suspended eligibility

03 Re-institutionalized

04 Died

05 Moved

06 No longer needed services

07 Other

99 Unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value is ‘99’ 301

ELIGIBLE FILE

Data Element Name: MFP-REINSTITUTIONALIZED-REASON (1 -2)

Definition: A code describing reason why individual was re-institutionalized after participation in the Money Follows the Person Demonstration.

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements:

Valid Values Code Definition

00 Default- Non Participation

01 Acute care hospitalization followed by long term rehabilitation

02 Deterioration in cognitive functioning

03 Deterioration in health

04 Deterioration in mental health

05 Loss of housing

06 Loss of personal care giver

07 By request of participant or guardian

08 Lack of sufficient community services

99 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values 812

2. Value is ‘99’ 301

ELIGIBLE FILE

Data Element Name: MFP-QUALIFIED-INSTITUTION (1- 4)

Definition: A code describing type of qualified institution at the time of transition to the community for an eligible MFP Demonstration participant.

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements:

Valid Values Code Definition

00 Default- Non Participation

01 Nursing Facility

02 ICF/MR (Intermediate Care Facilities for individuals with Mental Retardation)

03 IMD (Institution for Mental Diseases)

04 Hospital

05 Other

99 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is 9-filled 301

ELIGIBLE FILE

Data Element Name: MFP-QUALIFIED-RESIDENCE (1 – 2)

Definition: A code describing type of qualified residence at the end of the quarter or the end of the enrollment period if MFP (Money Follows the Person) eligibility ends during the quarter.

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements:

Valid Values Code Definition

00 Default- Non Participation

01 Home owned by participant

02 Home owned by family member

03 Apartment leased by participant, not assisted living

04 Apartment leased by participant, assisted living

05 Group home of no more than 4 people

99 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is 99 301

ELIGIBLE FILE

Data Element Name: MFP-LIVES-WITH-FAMILY (1 - 2)

Definition: A code describing type of qualified residence at the end of the quarter or the end of the enrollment period if MFP (Money Follows the Patient) eligibility ends during the quarter.

Field Description:

COBOL Example

PICTURE Value

9(02) “01”

Coding Requirements:

Valid Values Code Definition

00 Default- Non Participation

01 YES

02 NO

99 Unknown

Error Condition Resulting Error Code

1. Value is not in valid values list ???

2. Value is 99 301

ELIGIBLE FILE

Data Element Name: MSIS-CASE-NUM

Definition: The state-assigned number which uniquely identifies the Medicaid case to which the enrollee belongs on the last day of the current Federal Fiscal Year Month. The definition of a case varies. There are single-person cases (mostly aged and blind/disabled) and multi-person cases (mostly TANF) in which each member of the case have the same case number, but a unique MSIS identification number. A warning for longitudinal research efforts: a person’s case number may change over time.

Field Description:

COBOL Example

PICTURE Value

X(12) “001045329867”

Coding Requirements:

This field must contain the Medicaid case identification number assigned by the State. The format of the Medicaid case identification number must be supplied to CMS.

If multiple MSIS-CASE-NUMs exist at the state-level, and TMSIS only allows one Case Number in current TMSIS DD, please enter the Case Number with the longest eligibility days in that particular month. (CMS is discussing the possibility of adding multiple MSIS-CASE-NUM in the DD, but before that is decided/changed, please enter the MSIS-CASE-NUM with longest days.)

Error Condition Resulting Error Code

1. Duplicate Eligible Record (MSIS-IDENTIFICATION-NUMBER, MSIS-CASE-NUMBER, 801

FEDERAL-FISCAL-YEAR-MONTH DATE-OF-BIRTH SSN match)

2. Value is improperly “Space Filled” 303

3. Value is 9-filled 301

4. Value is 0-filled 304

5. Value is 8-filled 305

ELIGIBLE FILE

Data Element Name: MSIS-IDENTIFICATION-NUM

Definition: A unique identification number used to identify an individual who is eligible to Medicaid or CHIP.

Field Description:

COBOL Example

PICTURE Value

X(20) “123456789”

Coding Requirements:

For SSN States, this field should be space-filled unless a temporary identification number has been assigned. Whenever such a temporary MSIS-ID is in effect, enter that number in this field. When a permanent SSN is assigned carry the temporary number in this field to enable CMS to establish a link between the SSN and the temporary ID.

For Non-SSN States, this field must contain an identification number assigned by the State. The format of the state MSIS-ID numbers must be supplied to CMS with the state's MSIS application.

Error Condition Resulting Error Code

1. Duplicate Eligible record (MSIS-IDENTIFICATION-NUMBER, MSIS-CASE-NUMBER, 801

FEDERAL-FISCAL-YEAR-MONTH, DATE-OF-BIRTH match)

Second record is not saved.

2. Non-unique Duplicate (DATE-OF-BIRTH does not match; but 802

MSIS-IDENTIFICATION-NUMBER, FEDERAL-FISCAL-YEAR-MONTH

do match - Eligible with oldest DATE-OF-BIRTH saved)

3. Value is improperly "Space Filled” 303

4. Value is 9-filled 301

5. Value is 0-filled 304

6. Value is 8-filled 305

ELIGIBLE FILE

Data Element Name: NEWBORN-IND

Definition: A flag indicating the infant was born within the reporting month.

Field Description:

COBOL Example

PICTURE Value

9(01) “1”

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is ‘9’ 301

3. Value is equal to ‘1’ and year/month of DATE-OF-BIRTH 505

<> FEDERAL-FISCAL-YEAR-MONTH

4. Value is equal to ‘1’ and BASIS-OF-ELIGIBILITY is not equal to ‘4’, ‘6’, or ‘8’ 505

ELIGIBLE FILE

Data Element Name: PREGNANCY-IND

Definition: A flag indicating the individual is pregnant during the reporting month.

Field Description:

COBOL Example

PICTURE Value

9(01) “1”

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is ‘9’ 301

3. Value is equal to ‘1’ and SEX <> ‘F’ 539

ELIGIBLE FILE

Data Element Name: PRIMARY-LANGUAGE-IND

Definition: A flag indicating whether the individual speaks a language other than English at home (5 years old or older)

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not numeric 812

2. Value is ‘9’ 301

3. Value is not = ‘0’, ‘1’, or ‘9’ 203

ELIGIBLE FILE

Data Element Name: PRIMARY-LANGUAGE-ENGL-PROF-IND

Definition: A flag indicating the level of spoken English proficiency by the eligible person (5 years old or older).

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 Very Well

1 Well

2 Not well

3 No spoken proficiency

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is ‘9’ 301

ELIGIBLE FILE

Data Element Name: RACE (1 – 14)

Definition: A code indicating the individual’s race according to Section 4302 of the Affordable Care Act classifications..

Field Description:

COBOL Example

PICTURE Value

9(03) “003”

Coding Requirements:

Definitions:

The racial and ethnic categories for Federal statistics and program administrative reporting are defined as follows:

a. American Indian or Alaskan Native..

(1) Indian means any individual defined at 25 USC 1603(c), 1603(f), or 1679(b), or who has been determined eligible as an Indian, pursuant to § 136.12 of this part. This means the individual:

(i) Is a member of a Federally-recognized Indian tribe;

(ii) Resides in an urban center and meets one or more of the following four criteria:

(A) Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member;

(B) Is an Eskimo or Aleut or other Alaska Native;

(D) Is determined to be an Indian under regulations promulgated by the Secretary;

(iii) Is considered by the Secretary of the Interior to be an Indian for any purpose; or

(iv) Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native.

b. Asian. See specific country of origin below.

c. Black. A person having origins in any of the black racial groups of Africa.

d. Pacific Islander or Native Hawaiian. See specific breakout of island contained in the list of valid values.

e. White. A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Valid Values Code Definition

001 White

002 Black or African American

003 American Indian or Alaskan Native

004 Asian Indian

005 Chinese

006 Filipino

007 Japanese

008 Korean

009 Vietnamese

010 Other Asian

011 Native Hawaiian

012 Guamanian or Chamorro

013 Samoan

014 Other Pacific Islander

888 Unspecified

999 Unknown

Error Condition Resulting Error Code

Value is not in list of valid values……………… ???

2. Value is 9-filled ………………………………………………………………………………………….. 301

ELIGIBLE FILE

Data Element Name: RESTRICTED-BENEFITS-CODE

Definition: A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to.

Field Description:

COBOL Example

PICTURE Value

9(01) 2

Coding Requirements:

Valid Values Code Definition

0 Individual is not eligible for Medicaid.

1 Individual is eligible for Medicaid and entitled to the full scope of Medicaid benefits.

2 Individual is eligible for Medicaid but only entitled to restricted benefits based on alien status.

3 Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status (e.g., QMB, SLMB, QDWI, QI).

4 Individual is eligible for Medicaid but only entitled to restricted benefits for pregnancy-related services.

5 Individual is eligible for Medicaid but, for reasons other than alien, dual-eligibility or pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based upon substance abuse, medically needy or other criteria).

6 Individual is eligible for Medicaid but only entitled to restricted benefits for family planning services.

7 Individual is eligible for Medicaid and entitled to Medicaid under Benchmark Coverage..

8 Individual is eligible for Medicaid and entitled to benefits under a “Money Follows the Person” (MFP) rebalancing demonstration, as enacted by the Deficit Reduction Act of 2005, to allow States to develop community based long term care opportunities.

9 Individual's benefit restrictions are unknown.

A Individual is eligible for Medicaid and entitled to benefits under the Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF), as enacted by the Deficit Reduction Act of 2005. PRTF grants assist States to help provide community alternatives to psychiatric resident treatment facilities for children.

B Individual is eligible for Medicaid and entitled to Medicaid benefits using a Health Opportunity Account (HOA)

C Individual is eligible for S-CHIP dental coverage (supplemental dental wraparound benefit to employer-sponsored insurance)

Error Condition Resulting Error Code

1. Value is SPACE FILLED 303

2. Value is 9 301

3. Value is < 0 OR Value is > 8 and not = A, B or C 203

4. Value is 0 502

5. Value = 3 AND DUAL-ELIGIBLE-CODE = 00,02,04 OR 08 537

6. Value = 4 AND SEX-CODE <> “F” 539

7. Value = 4 AND PREGNANCY-IND <> ‘1’ 539

ELIGIBLE FILE

Data Element Name: SEX

Definition: The individual’s gender.

Field Description:

COBOL Example

PICTURE Value

X(01) “F”

Coding Requirements:

Valid Values Code Definition

F Female

M Male

U Unknown

Error Condition Resulting Error Code

1. Value is Numeric - 812

2. Value is “U” 301

3. Value is not “F”, “M”, “U” 203

ELIGIBLE FILE

Data Element Name: SSDI-IND

Definition: A flag indicating if the individual is enrolled in Social Security Disability Insurance (SSDI) administered via the Social Security Administration (SSA).

Field Description:

COBOL Example

PICTURE Value

9(01) 0

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is ‘9’ 301

ELIGIBLE FILE

Data Element Name: SSI-IND

Definition: A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is ‘9’ 301

ELIGIBILITY FILE

Data Element Name: SSI-STATE-SUPPLEMENT-STATUS-CODES

Definition: Indicates the individual's SSI State Supplemental Status.

Field Description:

COBOL Example

PICTURE Value

X(03) “002”

Coding Requirements: Required.

Valid Values Code Definition

000 Not Applicable

001 Mandatory

002 Optional

999 Unknown

Error Condition Resulting Error Code

1. Value = "999" 301

2. Value is not in the valid values list ???

ELIGIBILITY FILE

Data Element Name: SSI-STATUS

Definition: Indicates the individual's SSI Status.

Field Description:

COBOL Example

PICTURE Value

X(03) “001”

Coding Requirements: Required.

Valid Values Code Definition

000 Not Applicable

001 SSI

002 SSI Eligible Spouse

003 SSI Pending a Final Determination of Disposal of Resources Exceeding SSI Dollar Limits

999 Unknown

Error Condition Resulting Error Code

1. Value = "999" 301

2. Value is not in the valid values list ???

ELIGIBLE FILE

Data Element Name: SSN

Definition: The eligible individual's social security number.

Field Description:

COBOL Example

PICTURE Value

9(09) 253981873

Coding Requirements:

For SSN States:

Value must = individual's valid Social Security Number and SSN-INDICATOR = 1. If the SSN is not available and a temporary identification number has been assigned in the MSIS-IDENTIFICATION-NUMBER field, this field must = 888888888.

Value should contain numeric characters only (i.e., no letters, dashes, spaces, etc.)

For NON-SSN States:

Value should = individual's SSN or 999999999 if the SSN is unknown.

All States must provide available SSNs on the eligible file, regardless of the use of this field as the unique MSIS identifier.

See instructions under the Header Record Data Element SSN-INDICATOR, above, for examples concerning the rules for filling in the SSN-INDICATOR, SOCIAL-SECURITY-NUMBER, and MSIS-IDENTIFICATION-NUMBER fields.

Error Condition Resulting Error Code

1. Value contains invalid characters 811

2. Value is 999999999 301

3. Value=888888888 AND SSN-INDICATOR in the Header Record =1 305

AND MSIS-IDENTIFICATION-NUMBER is equal to spaces

ELIGIBLE FILE

Data Element Name: SSN-VERIFICATION-FLAG

Definition: Indicates the individual is enrolled in Medicaid pending social security number verification.

Field Description:

COBOL Example

PICTURE Value

9(01) 0

Coding Requirements:

Valid Values Code Definition

No, enrollment in Medicaid is not pending SSN verification.
Yes, enrollment in Medicaid is pending SSN verification.

Unknown

Error Condition Resulting Error Code

1. Value is not in the valid values list ???

2. Value is “9” 301

ELIGIBILE FILE

Data Element Name: STATE-PLAN-OPTION-END-DATE (1-5)

Definition: The date on which the individual’s participation in the State Plan Option Type ended.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If the SSN not applicable enter all 8s.

If it is nknown when the SOCIAL-SECURITY-NUMBER person’s participation in the State Plan Option type ended, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value is empty even though there is a corresponding STATE PLAN OPTION TYPE (1-5) value - ???

ELIGIBILITY FILE

Data Element Name: STATE-PLAN-OPTION-START-DATE (1-5)

Definition: The date on which the individual’s participation in the State Plan Option Type began.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If it is unknown when the person’s participation in the State Plan Option Type started, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value is empty even though there is a corresponding STATE-PLAN-OPTION-TYPE (1-5) value - ???

ELIGIBILITY FILE

Data Element Name: STATE-PLAN-OPTION-TYPE (1-5)

Definition: This field specifies the State Plan Options in which the individual is enrolled. Use on occurrence for each State Plan Option enrollment.

Field Description:

COBOL Example

PICTURE Value

X(02) “06”

Coding Requirements: Required.

Valid Values Code Definition

00 Not Applicable

01 Community First Choice

02 1915(i)

03 1915(j)

04 1932(a)

05 1915(a)

06 1937 (Alternative Benefit Plans)

99 Unknown

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is not in the valid values list ???

ELIGIBLE FILE

Data Element Name: STATE-SPEC-ELIG-GROUP

Definition: The composite of eligibility mapping factors used to create the corresponding Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) values. Examples of such mapping factors include:

- State eligibility group or aid category

- Payment status

- Disability status

- Family status

- Person code

- Money code

This field should not include information that already appears elsewhere on the Eligible-File record even if it is part of the MAS and BOE algorithm (e.g., age information computed from DATE-OF-BIRTH or COUNTY-CODE).

Field Description:

COBOL Example

PICTURE Value

X(06) “10A01”

Coding Requirements:

Concatenate alpha numeric representations of the eligibility mapping factors used to create monthly MAS and BOE. State needs to provide composite code reflecting the contents of this field (e.g., bytes 1-2 = aid category; bytes 3 = money code; bytes 4-5 = person code). If six bytes is insufficient to accommodate all of the eligibility factors, the state should select the most critical factors and include them in this field.

Value = 000000 for individuals who were not eligible for at least one day during the month.

Value must be one of the valid codes submitted by the State. (States must submit lists of valid State specific eligibility factor codes to CMS in advance of transmitting T-MSIS files, and must update those lists whenever changes occur.)

For this field, always report whatever is present in the State system, even if it is clearly invalid. Fill this field with "9"s only when the State system contains no information.

Error Condition Resulting Error Code

1 Value does not appear on the list of valid codes 201

submitted by the State.

2 Value = “000000" and DAYS-OF-ELIGIBLITY NOT =+00 …………………………………………… ???

3 Value = ‘000000” and DAYS-OF-ELIGIBLITY NOT =+00 and CHIP-CODE<> ‘3” ……………….. ???

4 Value > “000000” in any month later than the month that included DATE-OF-DEATH ………… ???

ELIGIBLE FILE

Data Element Name: TANF-CASH-CODE

Definition: A flag that indicates whether the individual received Temporary Assistance for Needy Families (TANF) benefits.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 Individual was not eligible for Medicaid.

1 Individual did not receive TANF benefits.

2 Individual did receive TANF benefits (States should only use this value if they can accurately separate eligible receiving TANF benefits from other 1931 eligible reported into MAS 1)

9 Individual’s TANF status is unknown

Error Condition Resulting Error Code

1. Value is Non-Numeric - 812

2. Value is 9-filled 301

3. Value is < 0 or > 2 203

4. Value = 0 502

ELIGIBLE FILE

Data Element Name: TYPE-OF-LIVING-ARRANGEMENT

Definition: A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid values listing.

Field Description:

COBOL

PICTURE

X(100)

Example Values:

Private Living Arrangement (PLA)

Examples of PLAs:

Home or apartment
Commercial boarding house or rooming house
Adult Care Home (formerly domiciliary care facility)
Residential treatment facility
Educational or vocational facility
Hotel and motel
Group living arrangement or supervised independent living licensed by Mental Health
Homeless or emergency homeless shelter
A general/acute care hospital, psychiatric unit of a state mental hospital or Psychiatric Residential Treatment Facility (PRTF), when the stay does not exceed 30 continuous days.

Long Term Care Living Arrangement (LTCLA)

Note: Only those individuals who live in a medical facility as defined in MA-2270, Long Term Care are considered to be in a long term care living arrangement.

Examples of LTCLAs:

A nursing facility for SNF, ICF, ICF-MR, SNF Rehab, hospice, or
Nursing level of care in a hospital (usually called a swing bed or inappropriate level of care bed), or
A general/acute care hospital, psychiatric unit of a state mental hospital, or PRTF stay that exceeds 30 continuous days or ends with Coding Requirements:

Valid characters in the text string are limited to alpha characters (A-Z, a-z), numbers (0-9), dashes (“-“), commas (“,”), and periods (“.”).

Error Condition Resulting Error Code

1. The text string contains invalid characters ???

ELIGIBLE FILE

Data Element Name: TYPE-OF-RECORD

Definition: A code indicating whether the eligibility information contained in this record refers to the current fiscal month (the month specified in the Header Record) or to a previous month. A previous month could pertain to either retroactive eligibility or to a record that corrects eligibility information submitted in an earlier month.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

1 For all ELIGIBLE File records that contain eligibility information pertaining to the current federal fiscal month, that is, to the reporting month specified in the Header Record.

2 For all ELIGIBLE File records that contain eligibility data pertaining to a retroactive month of eligibility, that is, to a month earlier than the reporting month specified in the Header Record. Although records with TYPE-OF-RECORD = 2 refer to prior months of eligibility, they must contain only information being reported for the first time.

3 For all ELIGIBLE File records that contain eligibility data that corrects or updates previously reported information pertaining to a month earlier than the reporting month specified in the Tape Label Internal Dataset Name. These records correct information in all prior month records, regardless of whether they were originally submitted with TYPE-OF-RECORD = 1 or 2.

9 If TYPE-OF-RECORD is unknown.

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value = 9 301

ELIGIBLE FILE

Data Element Name: VETERAN-IND

Definition: A flag indicating if the individual served in the active military, naval, or air service.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

Valid Values Code Definition

0 NO

1 YES

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is ‘9’ 301

ELIGIBILE FILE

Data Element Name: WAIVER-ENROLLMENT-END-DATE (1-4)

Definition: Date an individual's enrollment under a particular waiver ended.

Field Description:

COBOL Example

PICTURE Value

9(08) 20121001

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If the effective date is unknown, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 301

3. Value is not a valid date 102

4. Value is empty even though there is a corresponding WAIVER-ID (1-4) value ???

ELIGIBILE FILE

Data Element Name: WAIVER-ENROLLMENT-START-DATE (1-4)

Definition: Date an individual's enrollment under a particular waiver began.

Field Description:

COBOL Example

PICTURE Value

9(08) 20121001

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If the effective date is unknown, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 301

3. Value is not a valid date 102

4. Value is empty even though there is a corresponding WAIVER-ID (1-4) value ???

ELIGIBLE FILE

Data Element Name: WAIVER-ID (1 – 4)

Definition: Fields specifying the waivers or demonstrations for which an eligible individual is enrolled. These IDs must be the approved, full federal waiver ID number assigned during the State submission and CMS approval process. The categories of demonstration and waiver programs include: 1915(b)(1) ; 1915(b)(2) ; 1915(b)(3) and 1915(b)(4) managed care waivers; 1915(c) home and community based services waivers; combined 1915 (b) and 1915(c) managed home and community based services waivers and 1115 demonstrations.

Field Description:

COBOL Example

PICTURE Value

X(20) “000000000000000000C1”

Coding Requirements:

Please fill in the WAIVER-ID fields in sequence (e.g., if an individual is enrolled in two waivers, only the first and second fields should be used—8 fill the WAIVER-ID3 and WAIVER-ID4 fields. If only enrolled in one waiver, code WAIVER-ID1 and 8-fill WAIVER-ID2 through WAIVER-ID4).

Enter the WAIVER-ID number assigned by the State, and reported in the hard-copy documentation.

If individual is not enrolled in waiver, 8-fill all four fields.

Error Condition Resulting Error Code

Value is ”SPACE-FILLED”……………………………………………………………………………….… 303

2. Value is not 8-filled AND corresponding WAIVER-TYPE = 00 or 88 538

3. Value is 8-filled AND corresponding WAIVER-TYPE = 01 THROUGH 09 or 99 538

4. Value appears more than once AND VALUE <> 8-filled……………………….……......................... 532

ELIGIBLE FILE

Data Element Name: WAIVER-TYPE (1 – 4)

Definition: Codes for specifying up to four waiver types under which the eligible individual is covered during the month.

Field Description:

COBOL Example

PICTURE Value

9(02) 03

Coding Requirements:

Please fill in the WAIVER-TYPE fields in sequence (e.g., if an individual is enrolled in two waivers, only the first and second should be used; if only enrolled in one waiver, code WAIVER-TYPE1 and 8-fill WAIVER-TYPE2 through WAIVER-TYPE4).

Values must correspond to associated WAIVER-ID.

Valid Values Code Definition

00 Not Eligible – The individual was not eligible for Medicaid

01 1115 demonstration – Such waivers may also be called a research, experimental, demonstration or pilot waiver, or refer to consumer-directed care or expanded eligibility. It may cover the entire state or just a geographic entity or specific population.

02 1915(b)(1) – These waivers permit freedom-of-choice or mandatory managed care with some voluntary managed care...

03 1915(b)(2) – These waivers allow states to use enrollment brokers..

0404 1915(b)(3) – These waivers allow states to use savings to provide additional services that are not in the State Plan.. .

05 1915(b)(4) – These waivers allow fee for service selective contracting.

06 1915(c) – Aged and Disabled

07 1915(c) – Aged

08 1915(c) – Physical Disabilities

09 1915(c) – Intellectual Disabilities

10 1915(c) – Mental Illness and/or Serious Emotional Disturbance

11 1915(c) – Brain Injury

12 1915(c) – HIV/AIDS

13 1915(c) – Technology Dependent or Medically Fragile

14 1915(c) –Disabled (other)

15 Concurrent 1915(b)(c) – A concurrent HCBS/1915(c) waiver is one where the approved waiver services are delivered through a managed care authority – e.g., 1115(a), 1915(a), 1915(b), or 1932(a)

16 HIFA Waiver – The associated Waiver-ID is for a HIFA (Health Insurance and Flexibility and Accountability) waiver. May also be called demonstration waiver or refer to the eligibility expansion.

17 Pharmacy Waiver – The associated Waiver-ID is for Pharmacy waiver coverage. Includes waivers under 1115 demonstration authority which are primarily intended to increase coverage or expand eligibility for pharmacy benefits. The associated Waiver-ID is for another type of waiver.

18 Disaster-Related Waiver – The associated Waiver-ID is for a disaster-related waiver that allows for coverage related to a hurricane or other disaster.

19 Family Planning-ONLY waiver – The associated Waiver-ID-Number is for a Family Planning-ONLY waiver. In these waivers, the beneficiary’s Medicaid-covered benefits are restricted to Family Planning Services.

88 Not Applicable - The individual is eligible for Medicaid, but is NOT enrolled in a waiver.

99 Unknown – The associated Waiver-ID is for an unknown type of waiver.

Error Condition Resulting Error Code

1. Value is 99-filled 301

2. Value is not valid 203

3. Value = ‘00’ or ‘88’ AND corresponding WAIVER-ID is not 8-filled 502

ELIGIBLE FILE

Data Element Name: ZIP-CODE

Definition: Zip code of individual’s place of residence.

Field Description:

COBOL Example

PICTURE Value

9(9) 21365

Coding Requirements:

Value must be a valid U. S. Postal Service ZIP Code for the State.

Redefined as 9(05) and 9(04)

9(05) is needed If value is unknown fill with 99999

9(04) could be zero filled

Error Condition Resulting Error Code

1. Value is Non-Numeric 812

2. Value is 99999 301

3. Value is not a valid ZIP Code for the State specified 507

by STATE-ABBREVIATION in the Header Record

4. Value is not a valid ZIP-CODE for COUNTY-CODE specified 531

THIRD PARTY LIABILITY (TPL) FILE

THIRD PARTY LIABILITY (TPL) File - Data Field/Element Specifications

The following pages contain detailed specifications for each data element (field) in the TMSIS TPL file record. In this section, the data elements are listed in alphabetical order.

General directions for building the TPL file.

Each record represents distinct combinations of the following data elements:

MSIS-IDENTIFICATION NUM
INSURANCE-CARRIER-ID-NUM
INSURANCE-BENEFIT-PLAN-ID
GROUP-NUM

There can be as many records as is necessary to document each beneficiary’s TPL coverage. Because a single policy can contain multiple categories of coverage, the record allows for up to 16 COVERAGE-TYPE values.

With each monthly load, TPL data for all beneficiaries who have third party insurance should be included in file, even if there is no specific third party correspondence that month.

TPL FILE – HEADER RECORD

Header Record Data Element Name: DATE-FILE-CREATED

Definition: The date of which the file was created.

Field Description:

COBOL Example

PICTURE Value

9(8) 19870115

Coding Requirements:

Date format should be CCYYMMDD (National Data Standard).

Date must be equal to or later than date in END-OF-TIME-PERIOD.

Error Condition Resulting Error Code

1. Value is Non-Numeric .................................................................................................... 814

2. Value is not a valid date ................................................................................................. 102

3. Value is < End-of-Time-Period ....................................................................................... 501

TPL FILE – HEADER RECORD

Header Record Data Element Name: END-OF-TIME-PERIOD

Description: Last date of the reporting period covered by the file to which this Header Record is

Attached

Field Description:

COBOL Example

PICTURE Value

9(08) 19871231

Coding Requirements:

For Third Party Liability file submissions, END-OF-TIME-PERIOD represents the last day of the reporting period covered by the file. The format is CCYYMMDD based on the calendar year.

For example, “20120131” represents the last day of the first month of calendar year 2012 – January 31, 2012 – not the last day of the first month of federal fiscal year 2012 (which is October 31, 2011).

Under current submission conventions, states are expected to submit TPL files monthly. Hence, the state will submit 12 TPL files every year (one for every calendar month) and the day value of END-OF-TIME-PERIOD will always be the last day of the calendar month.

Error Condition Resulting Error Code

1. Value is Non-Numeric ......................................................................................................................... 814

2. Value is not a valid date ..................................................................................................................... 102

3. Value is > DATE-FILE-CREATED ....................................................................................................... 501

TPL FILE – HEADER RECORD

Header Record Data Element Name: FILE-NAME

Description: The name of the file to which this Header Record is attached. The name of the file also specifies the type of records contained in the file.

Field Description:

COBOL Example

PICTURE Value

X(08) NONCLMTP

Coding Requirements:

Valid Values Code Definition

NONCLMTP Third Party liability insurance file

Error Condition Resulting Error Code

Value is not one of the allowable file names listed above .................................................................... 201

Value is different from file name contained in the Tape Label Internal Dataset Name............................. 402

TPL FILE – HEADER RECORD

Header Record Data Element Name: FILE-STATUS-INDICATOR

Description: The test or production status of the file.

Field Description:

COBOL Example

PICTURE Value

X(01) P

Coding Requirements:

Valid Values Code Definition

P Production file – A production TPL file contains records documenting all non-Medicaid coverage and all other third party liability (estate claims, liens, and liability claims (Worker’s Compensation, casualty/tort, medical malpractice)) that are open for an enrollee applicable to a Medicaid/CHIP enrollee during the reporting period. Coverage can take the form of health insurance where a spouse or other family member is the policy holder. Coverage may also consist of casualty insurance adjudications awarded to the enrollee. Casualty claims may be paid by an insurance carrier, but the coverage doesn’t belong to the Medicaid beneficiary in the same manner that a health insurance policy in which the Medicaid beneficiary is enrolled can be said to be the beneficiary’s insurance. Casualty claims are settled by negotiation between the injured party (or his representative) and the tort feasor (the party responsible for the injury). Most claims are settled by direct negotiation; some require judicial intervention. For these case, there is no adjudication, in the usual meaning of the word.

All records in production files relate to actual events.

T Test file – A test TPL file contains one or more fictitious records created to test one or more parts of the system’s functionality.

None of the records in test files relate to actual events.

Error Condition Resulting Error Code

Value is not “P” or “T”................................................................................................................ 201

TPL FILE – HEADER RECORD

Header Record Data Element Name: START-OF-TIME-PERIOD

Definition: Beginning date of the month covered by this file.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements:

For Third Party Liability file submissions, START-OF-TIME-PERIOD represents the first day of the reporting period covered by the file. The format is CCYYMMDD based on the calendar year.

For example, “20120101” represents the first day of the first month of calendar year 2012 – January 01, 2012 – not the first day of the first month of federal fiscal year 2012 (which is October 01, 2011).

Error Condition Resulting Error Code

Value is Non-Numeric ............................................................................................................. 814

2 Value is not a valid date........................................................................................................... 102

TPL FILE – HEADER RECORD

Header Record Data Element Name: STATE-ABBREVIATION

Definition: FIPS state alpha for each U.S. state, Territory, and the District of Columbia for the state submitting the file.

Field Description:

COBOL Example

PICTURE Value

X(02) ND

Coding Requirements:

Must be one of the following FIPS State abbreviations:AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1. Value is not in the list of valid values ............................................................................................................... ???

2. Value is different from State abbreviation contained .........................................................................................202.

in the Internal Dataset Name

TPL FILE

Data Element Name: ANNUAL-DEDUCTIBLE-AMT (1 – 4)

Definition: Annual amount paid each year by the enrollee in the plan before a health plan benefit begins.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 E000000020002E is the actual value of +200.25

The table below shows the ASCII value and its COMP3 signed numeric value equivalent.

ASCII Value	Corresponding Last Byte of a Signed Numeric COMP3 Value
0	{
1	A
2	B
3	C
4	D
5	E
6	F
7	G
8	H
9	I
-0	}
-1	J
-2	K
-3	L
-4	M
-5	N
-6	O
-7	P
-8	Q
-9	R

Coding Requirements: Required

If the amount is missing or invalid, fill with zeroes.

Error Condition Resulting Error Code

1. The field is a signed numeric value data element, but the last digit is not in the list of valid signed numeric COMP3 values …………………………………………………………………………………. ???

TPL FILE

Data Element Name: COVERAGE-TYPE

Definition: Code indicating the level of coverage being provided under this policy for the insured by the TPL carrier. (Occurs 16 times per INSURANCE-BENEFIT-PLAN-TYPE)

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements:

Valid Values Code Definition

00 No Coverage

01 Drug

02 Physician

03 Dental

04 Inpatient Hospital

05 Outpatient Hospital

06 Nursing Home

07 Vision

08 Durable Med Equip (rent)

09 Durable Med Equip (purchase)

10 Home Health

11 Mental health—outpatient

12 Mental health –inpatient

13 Psychiatric care- outpatient

14 Psychiatric care- inpatient

15 PT/OT/ST

16 Cancer

If code is unknown, 9-fill.

Error Condition Resulting Error Code

Value is not in the list of valid values ………………………………………………………….…………. ???
Value is 9-filled ………………………………………………………………………………….………….. ???

TPL FILE

Data Element Name: GROUP-NUM

Definition: The group number of the TPL policy.

Field Description:

COBOL Example

PICTURE Value

X(16) “A-502800-431-60”

Coding Requirements:

Left justify and pad unused bytes with spaces.

If Group Number does not apply, enter “NA”.

If code is unknown, 9-fill.

Error Condition Resulting Error Code

1 Value is space-filled ………………………………………………………………………………………. 812

2 Value is 9.filled …………………………………………………………………………………………….. ???

TPL FILE

Data Element Names: INSURANCE-BENEFIT-PLAN-ID

Definition: The identifier that the state uses to uniquely identify the benefit package under which the third party liability insurance carrier provides benefits to the beneficiary.

Field Description:

COBOL Example

PICTURE Value

X(12) “MED001356”

Coding Requirements:

Enter the payer’s insurance plan identification number assigned by the State.

Error Condition Resulting Error Code

Value is ”SPACE FILLED”.............................................................................................................303

TPL FILE

Data Element Names: HEALTH-INSURANCE-BENEFIT-PLAN-TYPE

Definition: Code to classify the entity providing TPL coverage.

Field Description:

COBOL Example

PICTURE Value

9(02) “01”

Coding Requirements:

Values must correspond to associated PLAN-ID.

Valid Values Code Definition

00 Not applicable, individual is eligible for Medicaid or CHIP but not enrolled in a health insurance plan

01 Comprehensive MCO

02 Traditional PCCM Provider

03 Enhanced PCCM Provider

04 HIO

05 Medical-only PIHP (risk or non-risk/non-comprehensive/with inpatient hospital or institutional services)

03 Behavioral managed care plan (Mental Health/Substance Use Disorder PIHP/PAHP)

04 Prenatal/delivery managed care plan

05 Long term care managed care plan (Long Term PIHP)

06 Program for All-Inclusive Care for the Elderly (PACE)

07 Network primary care case management managed care plan (Network-PCCM)

08 Transportation managed care plan (Transportation PAHP)

09 Non-Network primary care case management plan (Non-Network PCCM)

10 Disease management managed care plan (Disease Management PAHP)

11 PAHP (Medical only)

12 Comprehensive Managed Care and Long Term Care (hybrid)

06 Medical-only PAHP (risk or non-risk/non-comprehensive/no inpatient hospital or institutional services)

07 Long Term Care (LTC) PIHP

08 Mental Health (MH) PIHP

09 Mental Health (MH) PAHP

10 Substance Use Disorders (SUD) PIHP

11 Substance Use Disorders (SUD) PAHP

12 Mental Health (MH) and Substance Use Disorders (SUD) PIHP

13 Mental Health (MH) and Substance Use Disorders (SUD) PAHP

14 Dental PAHP

15 Transportation PAHP

16 Disease Management PAHP

17 Program for All-Inclusive Care for the Elderly (PACE)

18 Veterans Administration health benefits

19 Indian Health Service Program health benefits

20 TRICARE health benefits

21 Eligible enrolled in private LTC insurance

21 Fee-for-Service insurance

99 Insurance plan type is unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value is 9-filled 301

4. Value is <> 00 AND DAYS-OF-ELIGIBILITY= +00 AND CHIP-CODE <>”3" 502

5. Value = 00 AND DAYS-OF-ELIGIBILITY <> +00 502

6. Value is > 00 in any month later than the month that 504

included DATE-OF-DEATH

TPL FILE

Data Element Name: INSURANCE-CARRIER-ADDR-LN (1 – 3)

Definition: The actual physical location of the Third Party Liability (TPL) Insurance carrier including the street name and number, room or suite number or letter...

Field Description:

COBOL Example

PICTURE Value

X(28) “123, Any Lane”

Coding Requirements: Required

Line 1 is required and the other two lines can be blank.

Error Condition Resulting Error Code

1. Value = "9 filled if unknown" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

TPL FILE

Data Element Name: INSURANCE-CARRIER-CITY

Definition: The city of the Third Party Liability (TPL) Insurance carrier.

Field Description:

COBOL Example

PICTURE Value

X(28) “Baltimore”

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value = "9 filled if unknown" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

TPL FILE

Data Element Name: INSURANCE-CARRIER-ID-NUM

Definition: The state’s internal identification number of the Third Party Liability (TPL) Insurance carrier. If the state’s systems use the NAIC # as the carrier identifier, enter that number in this data element as well as in the INSURANCE-CARRIER-NAIC-CODE field.

Field Description:

COBOL Example

PICTURE Value

X(12) “00722 ”

Coding Requirements: Required

Left justify and pad unused bytes with spaces.

Error Condition Resulting Error Code

1 Value is 9-filled …………………………………………………………………………………………….. ???

2 Value is space-filled 303

3. Value is 0-filled 304

TPL FILE

Data Element Name: INSURANCE-CARRIER-NAIC-CODE

Definition: The National Association of Insurance Commissioners (NAIC) code of the Third Party Liability (TPL) Insurance carrier.

Field Description:

COBOL Example

PICTURE Value

9(10) 1234567890

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is 9-filled 301

2. Value is space-filled 303

3. Value is 0-filled 304

TPL FILE

Data Element Name: INSURANCE-CARRIER-NAME

Definition: The name of the Third Party Liability (TPL) Insurance carrier.

Field Description:

COBOL Example

PICTURE Value

X(30) “MEDCO-PAID PRESCRIPTION”

Coding Requirements: Required

Use only alphabetic characters, (A-Z, a-z), numerals (0-9), spaces ( ), dashes (-), periods (.), forward slashes (/).

Error Condition Resulting Error Code

1 Value = "99" 301

2 Value is “Space Filled” 303

3 Value is 0-filled 304

4 Value contains invalid characters ……………………………………………………………………….. ???

TPL FILE

Data Element Name: INSURANCE-CARRIER-PHONE-NUM

Definition: The telephone number of the billing entity responsible for billing a patient for healthcare services.

Field Description:

COBOL Example

PICTURE Value

X(10) 1234567890

Coding Requirements:

Valid telephone number including the area code.

Enter numeric characters only (i.e., do not include parentheses, dashes, periods, spaces, etc.)

If unknown, 9-fill.

Error Condition Resulting Error Code

1. Value is 9-filled …………………………………………………………………………………………. 301

2 Value contains invalid characters ……………………………………………………………………. ???

3 Value is space-filled …………………………………………………………………………………… 303

4 Value is 0-filled ………………………………………………………………………………………… 304

TPL FILE

Data Element Name: INSURANCE-CARRIER-STATE

Definition: The FIPS state alpha for the U.S. state, Territory, or the District of Columbia code of the Third Party Liability (TPL) Insurance carrier.

Field Description:

COBOL Example

PICTURE Value

X(02) “MD”

Coding Requirements: Required

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

TPL FILE

Data Element Name: INSURANCE-CARRIER-ZIP-CODE

Definition: The Zip Code of the billing entity responsible for billing a patient for healthcare services.

Field Description:

COBOL Example

PICTURE Value

9(09) 21030

Coding Requirements: Required

Redefined as 9(05) and 9(04)

9(05) is needed If value is unknown fill with 99999

9(04) could be zero filled

Error Condition Resulting Error Code

1. Value = "999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

TPL FILE

Data Element Name: MEMBER-ID

Definition: Member identification number as it appears on the card issued by the TPL insurance carrier.

Field Description: Required

COBOL Example

PICTURE Value

X(20) “W555-5-C000”

Coding Requirements: Required

Use only alphabetic characters, (A-Z, a-z), numerals (0-9), spaces ( ), dashes (-), periods (.), forward slashes (/).

Left justify and pad with trailing spaces.

If not applicable, 8-fill.

Error Condition Resulting Error Code

1 Value is 9-filled …………………………………………………………………………………... 303

2 Value is 0-filled …………………………………………………………………………………... 304

3 Value is space-filled ……………………………………………………………………………... 303

4 Value contains invalid characters ………………………………………………………………. ???

TPL FILE

Data Element Name: MEMBER-FIRST-NAME

Definition: The first name of the individual covered

Field Description:

COBOL Example

PICTURE Value

X(12) “Mickey”

Coding Requirements: Required

Use only alphabetic characters, (A-Z, a-z), numerals (0-9), spaces ( ), dashes (-), periods (.), forward slashes (/).

Left justify and pad with trailing spaces.

Error Condition Resulting Error Code

1 Value is 9-filled …………………………………………………………………………………... 303

2 Value is 0-filled …………………………………………………………………………………... 304

3 Value is space-filled ……………………………………………………………………………... 303

4 Value contains invalid characters ………………………………………………………………. ???

TPL FILE

Data Element Name: MEMBER-LAST-NAME

Definition: The last name of the individual covered

Field Description:

COBOL Example

PICTURE Value

X(17) “Mouse”

Coding Requirements: Required

Use only alphabetic characters, (A-Z, a-z), numerals (0-9), spaces ( ), dashes (-), periods (.), forward slashes (/).

Left justify and pad with trailing spaces.

If not applicable, 8-fill.

Error Condition Resulting Error Code

1 Value is 9-filled …………………………………………………………………………………... 303

2 Value is 0-filled …………………………………………………………………………………... 304

3 Value is space-filled ……………………………………………………………………………... 303

4 Value contains invalid characters ………………………………………………………………. ???

TPL FILE

Data Element Name: MEMBER-MIDDLE-INIT

Definition: The middle initial of the individual covered

Field Description:

COBOL Example

PICTURE Value

X(01) “R”

Coding Requirements: Required

Use only alphabetic characters, (A-Z, a-z) or space ( ).

Error Condition Resulting Error Code

1 Value contains invalid characters ………………………………………………………………. ???

TPL FILE

Data Element Name: MSIS-IDENTIFICATION-NUM

Definition: A state-assigned unique identification number used to identify a Medicaid Eligible to MSIS.

Field Description:

COBOL Example

PICTURE Value

X(20) 123456789

Coding Requirements: Required.

For SSN States, this field must contain the Eligible's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number.

For non-SSN States, this field must contain an identification number assigned by the State. The format of the State ID numbers must be supplied to CMS.

Error Condition Resulting Error Code

1. Value is space-filled 303

2. Value is 9-filled 301

3. Value is 0-filled 304

4. Value is 8-filled 305

TPL FILE

Data Element Name: OTHER-THIRD-PARTY-LIABILITY (Occurs 4 times)

Definition: This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed INSURANCE-BENEFIT-TYPE-PLAN.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements: Required

Valid Values Code Definition

1	Tort/Casualty Claim
2	Medical Malpractice
3	Estate (an estate or designated trust)
4	Liens
5	Worker’s Compensation
8	Other – unidentified
9	Unknown

Error Condition Resulting Error Code

1. Value is 9-filled 301

2. Value is space-filled 303

3. Value is 0-filled 304

TPL FILE

Data Element Name: POLICY-EFF-DATE

Definition: The date on which the individual’s eligibility for coverage under the policy began..

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 9-filled 301

3. Value is not a valid date 102

TPL FILE

Data Element Name: POLICY-EXP-DATE

Definition: The date on which the individual’s eligibility for coverage under the policy ended.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 9-filled 301

3. Value is not a valid date 102

4. Value is "Space-filled" 303

TPL FILE

Data Element Name: POLICY-OWNER

Definition: The first and last name of the owner of the insurance policy. For example, the owner of this may be the Medicaid beneficiary.

If the TPL insurance is noted under OTHER-THIRD-PARTY-LIABILITY, the liability policy owner information is not needed and 8-fill the POLICY-OWNER field.

If policy holder name and relationship are unknown, please 9-fill.

Field Description:

COBOL Example

PICTURE Value

X(30) “Mickey Mouse”

Coding Requirements: Conditional

Use only alphabetic characters, (A-Z, a-z), numerals (0-9), spaces ( ), dashes (-), periods (.), forward slashes (/).

Left justify and pad with trailing spaces.

Error Condition Resulting Error Code

1 Value is 9-filled …………………………………………………………………………………... 303

2 Value is 0-filled …………………………………………………………………………………... 304

3 Value is space-filled ……………………………………………………………………………... 303

4 Value contains invalid characters ………………………………………………………………. ???

TPL FILE

Data Element Name: POLICY-OWNER-CODE

Definition: This code identifies the relationship of the policy holder to the Medicaid beneficiary.

If policy holder name and relationship are unknown, 9-fill.

Field Description:

COBOL Example

PICTURE Value

9(01) “0”

Coding Requirements: Required

Valid Values Code Definition

1	Self
2	Spouse
3	Custodial Parent
4	Noncustodial Parent (Child Support Enforcement in effect)
5	Noncustodial Parent without child support enforcement in effect
6	Grandparent
7	Guardian
8	Other
9	Unknown

Error Condition Resulting Error Code

1. Value is 9-filled 301

2. Value is not in the list of valid values ???

TPL FILE

Data Element Name: POLICY-OWNER-SSN

Definition: The policy owner’s social security number.

Field Description:

COBOL Example

PICTURE Value

9(09) 253981873

Coding Requirements:

Enter numerals only (e.g., no dashes, spaces, periods, etc.).

If unknown, 9-fill

Error Condition Resulting Error Code

1 Value is 9-filled ……………………………………………………………………………………............. 301

2 Value contains invalid characters ???

CLAIMS FILES

The following Data Dictionary describes in detail the specifications for each data element (field) in the T-MSIS Claim type records (excluding the Standard Header Record). Data elements are listed in alphabetical order to facilitate locating information about a specific field. Examples are also provided which illustrate properly entered data elements.

CLAIMS FILE – FILE HEADER RECORD

Header Record Data Element Name: DATE-FILE-CREATED

Definition: The date on which the file was created.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(8) 19870115

Coding Requirements:

Date format should be CCYYMMDD (National Data Standard).

Date must be equal to or later than date in END-OF-TIME-PERIOD.

Error Condition Resulting Error Code

1. Value is Non-Numeric .................................................................................................... 814

2. Value is not a valid date ................................................................................................. 102

3. Value is < End-of-Time-Period ....................................................................................... 501

CLAIMS FILE – HEADER RECORD

Header Record Data Element Name: END-OF-TIME-PERIOD

Description: Last date of the reporting month covered by the file to which this Header Record is

Attached

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 19871231

Coding Requirements:

Date format should be CCYYMMDD (National Data Standard).

month

For ELIGIBLE File submissions, END-OF-TIME-PERIOD must always contain a month ending date (1/31, 2/28, 3/31,etc).

For CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX File submissions, however, END-OF-TIME-PERIOD reflects the date on which the state closes its monthly month. Several states close their books on dates other than the last day of each month.

It is essential that states assure that claims for days on or near the monthly cutoff date are counted in one and only one month.

Error Condition Resulting Error Code

1. Value is Non-Numeric ......................................................................................................................... 814

2. Value is not a valid date ..................................................................................................................... 102

3 For ELIGIBLE File submissions - ..................................................................................................... 203

Value is <> month ending date

4. Value is > DATE-FILE-CREATED ....................................................................................................... 501

CLAIMS FILE – HEADER RECORD

Header Record Data Element Name: FILE -NAME

Description: The name of the file to which this Header Record is attached. The name of the file also specifies the type of records contained in the file.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(08) CLAIMOT

Coding Requirements:

Valid Values Code Definition

ELIGIBLE Eligibles File

CLAIMIP Inpatient Claim/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 1, 24, 25, or 39.

(Note: In CLAIMIP, TYPE-OF-SERVICE 24 and 25 refer only to services received on an inpatient basis.)

CLAIMLT Long Term Care Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 02, 04, 05 or 07 (all mental hospital, NF services).

(Note: Individual services billed by a long-term care facility belong in this file regardless of service type.)

CLAIMOT Other Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 08 through 13, 15, 19 through 26, 30, 31, 33 through 39.

CLAIMRX Pharmacy Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 16 or 19.

Error Condition Resulting Error Code

Value is not one of the allowable file names ................................................................................................ 201

listed above

Value is different from file name contained in dataset.......................................................................................402

CLAIMS FILE – HEADER RECORD

Header Record Data Element Name: FILE-STATUS-INDICATOR

Description: The test or production status of the file.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) P

Coding Requirements:

Valid Values Code Definition

P or T or Space Production File –

ELIGIBLE Production Files must contain:

one record for each person who was eligible for Medicaid or CHIP during the reporting month.
for each person who was granted retroactive eligibility during the reporting month that covered a portion of a prior month one record must be included for each month covered and
records correcting prior month records that contained errors, if any.

CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX Production Files must contain:

one record of the appropriate claim/encounter type, for every separately adjudicated line item of every claim processed during the reporting month; and
one record for every adjustment to a prior month claim/encounter that was adjudicated during the reporting month.

Error Condition Resulting Error Code

Value is not “P” , “T” or Space ................................................................................................................ 201

CLAIMS FILE – HEADER RECORD

Header Record Data Element Name: START-OF-TIME-PERIOD

Definition: Beginning date of the Month covered by this file.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 19861001

Coding Requirements:

Date format should be CCYYMMDD (National Data Standard).

For CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX File submissions, however, START-OF-TIME-PERIOD reflects the date on which the state opens its fiscal accounting records for the month. Several states open their books on dates other than the first day of each month or month. Therefore, MSIS allows reporting months to start on any date between the fifteenth day of the third month of the previous month and the fifteenth day of the current reporting month.

It is essential that states assure that claims for days on or near the monthly cutoff date are counted in one and only one month.

Error Condition Resulting Error Code

1. Value is Non-Numeric .............................................................................................................. 814

2. Value is not a valid date........................................................................................................... 102

CLAIMS FILE – HEADER RECORD

Header Record Data Element Name: STATE-ABBREVIATION

Definition: FIPS state alpha for the U.S. state, Territory, or the District of Columbia code for the state submitting the file.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) ND

Coding Requirements:

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1. Value is not in the list of valid values ….............................................................................................. 201

CLAIM FILE

Data Element Name: 1115A-DEMONSTRATION-IND

Definition: Indicates that the individual participates in an 1115(A) demonstration.

Field Description:

COBOL Example

PICTURE Value

9(01) 0

Coding Requirements:

Valid Values Code Definition

1115(A) participant.
Not a 1115(A) participant.

Error Condition Resulting Error Code

1. Value is not in the valid values list 301

CLAIMS FILES

Data Element Name: ADJUDICATION-DATE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The date on which the payment status of the claim was adjudicated by the State.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Value must be a valid date in CCYYMMDD format.

For Encounter Records (TYPE-OF-CLAIM=3); use date the encounter was processed.

For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 301

3. Value is not a valid date - 102

4. Value < START-OF-TIME-PERIOD in the Header Record 514

5. Value > END-OF-TIME-PERIOD in the Header Record …………………………………………….... 506

CLAIMS FILES

Data Element Name: ADJUSTMENT-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX- Code indicating type of adjustment record claim/encounter represents.

Field Description:

COBOL Example

PICTURE Value

X(01) 2

Coding Requirements: Required

Valid Values Code Definition

0 Original Claim / Encounter

1 Void of a prior submission

2 Re-submittal

3 Credit Adjustment (negative supplemental)

4 Debit Adjustment (positive supplemental)

5 Credit Gross Adjustment.

6 Debit Gross Adjustment

9 Unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value = 9 301

3. Value = 5 AND TYPE-OF-CLAIM <>4 509

4. Value <> 5 AND TYPE-OF-CLAIM = 4 509

5. Value = 5 AND first byte of MSIS-IDENTIFICATION-NUMBER <> “&” 522

6. Value <> 5 AND first byte of MSIS-IDENTIFICATION-NUMBER = “&”- 522

CLAIMS FILES

Data Element Name: ADJUSTMENT-REASON-CODE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - Claim adjustment reason codes communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE)

Field Description:

COBOL Example

PICTURE Value

X(03) “D22”

Coding Requirements:

Conditional

See Appendix B where these code values and definitions are provided.

If claim record does not represent an adjustment, 8-fill.

(Source: http://www.wpc-edi.com/content/view/695/1 reference/codelists/healthcare/claim-adjustment-reason-codes/ )

Error Condition Resulting Error Code

1. Value = "999" 301

3. Value is “Space Filled” 303

4. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ADMISSION-DATE

Definition: CLAIMIP, CLAIMLT - The date on which the recipient was admitted to a hospital or long term care facility.

Field Description:

COBOL Example

PICTURE Value

9(08) 19980531

Coding Requirements: Required

Value must be a valid date in CCYYMMDD format.

If admission date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 301

3. Value is not a valid date 102

4. Value CC <19 OR >20. Value is not a valid date. . 102

5. Value > BEGINNING-DATE-OF-SERVICE 511

CLAIMS FILES

Data Element Name: ADMISSION-HOUR

Definition: CLAIMIP, CLAIMLT - The time of admission for inpatient claims or long term

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(02) 23

Coding Requirements: Required

Value must be a valid hour in military time format (00 to 23).

If admission hour is not known, fill with 99.

Valid Values Code Definition Valid Values Code Definition

AM PM

00 0:00-0:59 12 12:00-12:59

01 1:00-1:59 13 13:00-13:59

02 2:00-2:59 14 14:00-14:59

03 3:00-3:59 15 15:00-15:59

04 4:00-4:59 16 16:00-16:59

05 5:00-5:59 17 17:00-17:59

06 6:00-6:59 18 18:00-18:59

07 7:00-7:59 19 19:00-19:59

08 8:00-8:59 20 20:00-20:59

09 9:00-9:59 21 21:00-21:59

10 10:00-10:59 22 22:00-22:59

11 11:00-11:59 23 23:00-23:59

Error Condition Resulting Error Code

1. Value = "9999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ADMISSION-TYPE

Definition: CLAIMIP – The basic types of admission for Inpatient hospital stays and a code indicating the priority of this admission.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) “1”

Coding Requirements: Required

Valid Values Code Definition

1 EMERGENCY The patient requires immediate medical intervention as a result

of severe, life threatening or potentially disabling conditions. Generally, the patient is admitted through the emergency room.

2 URGENT The patient requires immediate attention for the care and

treatment of a physical or mental disorder. Generally, the patient is admitted to the first available and suitable accommodation.

3 ELECTIVE The patient’s condition permits adequate time to schedule the

availability of a suitable accommodation.

4 NEWBORN Use of this code necessitates the use of special Source of

Admission Codes.

8 TRAUMA Visit to a trauma center/hospital as licensed or designated by the

CENTER state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation.

0 OTHER

9 UNKNOWN

Error Condition Resulting Error Code

1. Value = "9" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ADMITTING-DIAGNOSIS-CODE

Definition: CLAIMIP, CLAIMLT - The ICD-9/10-CM Diagnosis Code provided at the time of admission by the Attending Physician.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(08) “760.0”

Coding Requirements: Required

The ICD-9/10-CM Diagnosis Code describing the Admitting Diagnosis as a significant finding representing patient distress, an abnormal finding on examination, a possible diagnosis based on significant findings, a diagnosis established from a previous encounter, an admission, an injury, a poisoning, a reason, or condition (not an illness or injury) such as follow-up or pregnancy in labor. Report only one Admitting Diagnosis.

Must be a valid ICD-9/10-CM code. To be valid, ICD-9/10-CM codes must be entered at the most specific level to which they are classified in the ICD-9/10-CM Tabular List. Three-digit codes further divided at the four-digit level must be entered using all four digits. Four-digit codes further sub-classified at the five-digit level must be entered using all five digits. Failure to enter all required digits in the diagnosis codes will cause the record to be rejected.
Must be entered exactly as shown in the ICD-9/10-CM coding reference.
E-codes are not valid as Admitting Diagnosis Codes.

Source: http://www.phc4.org/dept/dc/adobe/inpatientmanual.pdf

http://www.nyhealth.gov/statistics/sparcs/sysdoc/elements_837/admitting_diagnosis_code.htm

http://www.cms.hhs.gov/ICD10/02m_2009_ICD_10_CM.asp#TopOfPage

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ADMITTING –DIAGNOSIS-FLAG

Definition: CLAIMIP, CLAIMLT - A flag that identifies the coding system used for the ADMITTING DIAGNOSIS CODE.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 09

Coding Requirements: Required.

Valid Values Code Definition

01 ICD-9

02 ICD-10

03 Other

99 Unknown

Error Condition Resulting Error Code

CLAIMS FILES

Data Element Name: ADMITTING-PROV-NPI-NUM

Definition: CLAIMIP - The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(10) “1234567890”

Coding Requirements: Required

Record the value exactly as it appears in the State system. Do not 9-fill.

8-fill field for premium payments/admin fees (TYPE-OF-SERVICE = 20, 21, 22,23)

Error Condition Resulting Error Code

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1. Value = "9999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “8888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “8888888888" AND TYPE-OF-SERVICE = {20, 21, 22, 23} 306

CLAIMS FILES

Data Element Name: ADMITTING-PROV-NUM

Definition: CLAIMIP – The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

Note: Once a national provider ID numbering system is in place, the national number should be used.

If the State’s legacy ID number is also available then that number can be entered in this field.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ADMITTING –PROV-SPECIALTY

Definition: CLAIMIP – This code describes the area of specialty for the ADMITTING PROVIDER

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 97

Coding Requirements: Required.

http://www.cms.hhs.gov/medicareprovidersupenroll/downloads/taxonomy.pdf

http://www.cms.hhs.gov/Transmittals/downloads/R1715CP.pdf

Valid Values Code Definition

01 General Practice

02 General Surgery

03 Allergy/Immunology

04 Otolaryngology

05 Anesthesiology

06 Cardiology

07 Dermatology

08 Family Practice

09 Interventional Pain Management

10 Gastroenterology

11 Internal Medicine

12 Osteopathic Manipulative Therapy

13 Neurology

14 Neurosurgery

16 Obstetrics/Gynecology

17 Hospice and Palliative Care

18 Ophthalmology

19 Oral Surgery (dentists only)

20 Orthopedic Surgery

21 Available

22 Pathology

23 Available

24 Plastic and Reconstructive Surgery

25 Physical Medicine and Rehabilitation

26 Psychiatry

27 Available

28 Colorectal Surgery (formerly proctology)

29 Pulmonary Disease

30 Diagnostic Radiology

31 Available

32 Anesthesiologist Assistants

33 Thoracic Surgery

34 Urology

35 Chiropractic

36 Nuclear Medicine

37 Pediatric Medicine

38 Geriatric Medicine

39 Nephrology

40 Hand Surgery

41 Optometry

44 Infectious Disease

46 Endocrinology

48 Podiatry

66 Rheumatology

70 Single or Multispecialty Clinic or Group Practice

72 Pain Management

73 Mass Immunization Roster Biller

74 Radiation Therapy Center

75 Slide Preparation Facilities

76 Peripheral Vascular Disease

77 Vascular Surgery

78 Cardiac Surgery

79 Addiction Medicine

81 Critical Care (Intensivists)

82 Hematology

83 Hematology/Oncology

84 Preventive Medicine

85 Maxillofacial Surgery

86 Neuropsychiatry

90 Medical Oncology

91 Surgical Oncology

92 Radiation Oncology

93 Emergency Medicine

94 Interventional Radiology

98 Gynecological/Oncology

99 Unknown Physician Specialty

A0 Hospital

A1 Skilled Nursing Facility

A2 Intermediate Care Nursing Facility

A3 Other Nursing Facility

A4 Home Health Agency

A5 Pharmacy

A6 Medical Supply Company with Respiratory Therapist

A7 Department Store

A8 Grocery Store

99 Unknown

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ADMITTING-PROV-TAXONOMY

Definition: CLAIMIP

For CLAIMIP files the taxonomy code for the institution billing/caring for the beneficiary.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “207KA0200X”

Coding Requirements: Required.

If Value is unknown, fill with "999999999999".

Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.

Source: http://www.wpc-edi.com/content/view/793/1

Error Condition Resulting Error Code

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “888888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “888888888888" AND TYPE-OF-SERVICE = {20, 21, 22, 23} 306

CLAIMS FILES

Data Element Name: ADMITTING-PROV-TYPE

Definition: CLAIMIP - A code describing the type of entity admitting an individual to the hospital or long term care facility.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 01

Coding Requirements: Required

Valid Values Code Definition

01 General Hospital

02 Special Hospital/Outpatient Rehabilitation Facility

03 Psychiatric Hospital

05 Community Mental Health Center

19 End Stage Renal Hospital

20 Pharmacy

25 Physician (MD)

26 Physician (DO)

27 Podiatrist

28 Chiropractor

29 Physician Assistant

30 Advanced Registered Nurse Practitioner (ARNP)

31 CRNA

32 Psychologist

34 Licensed Midwife

35 Dentist

36 Registered Nurse (RN)

37 Licensed Practical Nurse (LPN)

38 Nursing Attendant

39 Massage Therapist

40 Ambulance

41 Contract Nurse

42 Air/Water Ambulance Company

43 Taxi

44 Public Transportation

45 Private Transportation

46 Hospice

50 Independent Laboratory

51 Portable X-Ray Company

52 Alternative Medicine

53 Non-Medical Vendor

54 Prosthetics/Orthotics

55 Vocational Rehabilitation (Training, Tuition and Schools)

56 Vocational Rehabilitation Counselor

57 Rehabilitation Maintenance

58 Assisted Re-employment

59 Relocation Expenses

60 Audiologist/Speech Pathologist

61 Second Opinion Contractor

62 Optometrist

63 Optician

65 Home Health Agency

66 Rural Health Clinic

68 Federally Qualified Health Center

69 Birthing Center

70 HMO or PHP

71 Physical Therapist

72 Occupational Therapist

73 Pulmonary Rehabilitation

74 Outpatient Renal Dialysis Facility

75 Medical Supplies/Durable Medical Equipment (DME)

76 Case Management Agency

77 Social Worker

78 Blood Bank

79 Alternative Payee

80 Pay-to-Intermediary

88 Ambulatory Surgery Center

89 Federal Facility (VA Hospital)

90 Skilled Nursing Facility (SNF)-Medicare Certified

91 Skilled Nursing Facility (SNF)-Non-Medicare Certified

92 Intermediate Care Facility (ICF)

93 Rural Hospital Swing Bed

94 Boarding House

95 Insurance Company (Third Party Carriers)

96 Other Provider

97 Billing Agent

98 Lien holder

99 Unknown

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ALLOWED-AMT

Definition: CLAIMLT, CLAIMOT, CLAIMRX - The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

CLAIMS FILES

Data Element Name: ALLOWED-CHARGE-SRC

Definition: CLAIMIP- These codes indicate how each allowed charge was determined.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) “R”

Coding Requirements: Required

Relevant to Medicaid Payment

Valid Values Code Definition Valid Values Code Definition

0 Bundled code pays zero D Percent of charges

1 Priced using QMB Pricing E Reimbursement Rate

2 Lab panel bundled G Billed Charges

4 Priced using RBRVS H Denied

5 Anesthesia pricing I Medicare Coins and deductible

7 APC priced K Medicare allowed amount

8 APC priced M Medicare prevailing

9 Lower level screening fee P DRG

A Manually priced R DRG w/cost outlier

B By report U DRG priced by proration

C Maximum fee V Mid-level priced

Z ATP Bundled

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: BEGINNING-DATE-OF-SERVICE

Definition: CLAIMIP, CLAIMLT, CLAIMOT - For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value > END-OF-TIME-PERIOD in the Header Record 605

AND TYPE-OF-SERVICE <> {20, 21, 22,23}

5. Value > ENDING-DATE-OF-SERVICE. 517

CLAIMS FILE

Data Element Name: BENEFICIARY-COINSURANCE-AMOUNT

Definition: The amount of money the beneficiary paid towards coinsurance.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If no coinsurance is applicable enter 0.00.

If it is unknown whether coinsurance was paid, enter all 9s.

Valid Values Code Definition

S9(11)V99 000000002002E

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

CLAIM FILE

Data Element Name: BENEFICIARY-COINSURANCE-DATE-PAID

Definition: The date the beneficiary paid the coinsurance amount.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If no coinsurance is applicable enter all 8s.

If it is unknown when coinsurance was paid, enter all 9s

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

CLAIM FILE

Data Element Name: BENEFICIARY-COPAYMENT-AMOUNT

Definition: The amount of money the beneficiary paid towards a copayment.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If no copayment is applicable enter 0.00.

If it is unknown whether a copayment was paid, enter all 9s.

Valid Values Code Definition

S9(11)V99 000000002002E

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = "999999999999" 301

CLAIM FILE

Data Element Name: BENEFICIARY-COPAYMENT-DATE-PAID

Definition: The date the beneficiary paid the coinsurance amount.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If no coinsurance is applicable enter all 8s.

If it is unknown when coinsurance was paid, enter all 9s

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

CLAIM FILE

Data Element Name: BENEFICIARY-DEDUCTIBLE-AMOUNT

Definition: The amount of money the beneficiary paid towards an annual deductible.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If no deductible is applicable enter 0.00.

If it is unknown whether a deductiblet was paid, enter all 9s.

Valid Values Code Definition

S9(11)V99 000000002002E

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = "999999999999" 301

CLAIM FILE

Data Element Name: BENEFICIARY-DEDUCTIBLE-DATE-PAID

Definition: The date the beneficiary paid the deductible amount.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If no coinsurance is applicable enter all 8s.

If it is unknown when coinsurance was paid, enter all 9s

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

CLAIM FILE

Data Element Name: BENEFIT TYPE

Definition: The benefit category corresponding to the service reported on the claim or encounter record.

Field Description:

COBOL Example

PICTURE Value

9(3) 001

Coding Requirements: Required

Valid Values Code Definition

1 Inpatient Hospital Services

2 Outpatient Hospital Services

3 Rural health clinic services

4 FQHC services

5 Laboratory and x-ray services

6 Nursing Facility Services for 21 and over

7 EPSDT

8 Family Planning Services

9 Physicians' Services

10 Medical and Surgical Services Furnished by a Dentist

11 Medical care and any type of remedial care recognized under State law - Podiatrists' Services

12 Medical care and any type of remedial care recognized under State law - Optometrists' Services

13 Medical care and any type of remedial care recognized under State law - Chiropractors' Services

14 Medical care and any type of remedial care recognized under State law - Other Practitioners' Services within scope of practice as defined by State law

15 Home Health Services - Intermittent or part-time nursing services provided by a home health agency

16 Home Health Services - Home health aide services provided by a home health agency

17 Home Health Services - Medical supplies, equipment, and appliances suitable for use in the home

18 Home Health Services - Physical therapy; occupational therapy; speech pathology; audiology provided by a home health agency

19 Private duty nursing services

20 Clinic Services

21 Dental Services

22 Physical Therapy and Related Services - Physical Therapy

23 Physical Therapy and Related Services - Occupational Therapy

24 Physical Therapy and Related Services - Services for individuals with speech, hearing and language disorders

25 Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Prescribed Drugs

26 Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Dentures

27 Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Prosthetic Devices

28 Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Eyeglasses

29 Other diagnostic, screening, preventive, and rehabilitative services - Diagnostic Services

30 Other diagnostic, screening, preventive, and rehabilitative services - Screening Services

31 Other diagnostic, screening, preventive, and rehabilitative services - Preventive Services

32 Other diagnostic, screening, preventive, and rehabilitative services - Rehabilitative Services

33 Services for individuals over age 65 in IMDs - Inpatient hospital services

34 Services for individuals over age 65 in IMDs - Nursing facility services

35 Intermediate Care Facility Services for individuals with mental retardation or persons with related conditions

36 Inpatient psychiatric facility services for under 22

37 Nurse-midwife services

38 Hospice Care

39 Case Management Services and TB related services - Case management services as defined in the State Plan in accordance with section 1905(a)(19) or 1915(g)

40 Case Management Services and TB related services - Special TB related services under section 1902(z)(2)

41 Special sickle-cell anemia-related services

42 Extended services for pregnant women - Additional Pregnancy-related and postpartum services for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60th day falls.

43 Extended services for pregnant women - Additional Services for any other medical conditions that may complicate pregnancy

44 Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period

45 Respiratory care services under 1902(e)9)(A) through (C)

46 Certified pediatric or family nurse practitioners' services

47 Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Transportation

48 Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Services provided in religious non-medical health care facilities

49 Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Nursing facility services for patients under 21

50 Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Emergency hospital services

51 Home and Community Care for Functionally Disabled Elderly individuals as defined and described in the State Plan

52 Personal care services in recipient's home

53 Emergency services for certain legalized aliens and undocumented aliens

55 Licensed or Otherwise State-Approved Free-Standing Birthing Center

56 Primary care case management services

57 Community First Choice

59 Homemaker

60 Home Health Aide

61 Personal Care Services

62 Adult Day Health services

63 Habilitation

64 Habilitation: Residential Habilitation

65 Habilitation: Supported Employment

66 Habilitation: Education (non IDEA available)

67 Habilitation: Day Habilitation

68 Habilitation: Pre-Vocational

69 Habilitation: Other Habilitative Services

70 Respite

71 Day Treatment (mental health service)

72 Psychosocial rehabilitation

73 Environmental Modifications (Home Accessibility Adaptations)

74 Vehicle Modifications

75 Non-Medical Transportation

76 Special Medical Equipment (minor assistive Devices)

77 Home Delivered meals

78 Assistive Technology (i.e., communication devices)

79 Personal Emergency Response (PERS)

80 Nursing Services

81 Community Transition Services

82 Adult Foster Care

83 Day Supports (non-habilitative)

84 Supported Employment

85 Supported Living Arrangements

86 Private Duty Nursing

87 Supports for Consumer Direction (Supports Facilitation)

88 Participant Directed Goods and Services

89 Senior Companion (Adult Companion Services)

90 Assisted Living

91 Other

Error Condition Resulting Error Code

1. Value = The value does not appear on the list of valid values ???

CLAIMS FILES

Data Element Name: BILLING-PROV-NPI-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services.

The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.

For encounter records (TYPE-OF-CLAIM = 3), this represents the entity billing (or reporting) to the managed care plan (See PLAN-ID-NUMBER for reporting capitation plan-ID). Capitation PLAN-ID should be used in this field only for premium payments (TYPE-OF-SERVICE = 20, 21, 22, 23)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(10) “1234567890”

Coding Requirements: Required

Record the value exactly as it appears in the State system.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22,23)

If Value is unknown, fill with "9999999999".

Error Condition Resulting Error Code

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1. Value = "9999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “8888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “8888888888" AND TYPE-OF-SERVICE = {20, 21, 22,23} 306

CLAIMS FILES

Data Element Name: BILLING-PROV-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A unique identification number assigned by the state to a provider or capitation plan. This should represent the entity billing for the service. For encounter records (TYPE-OF-CLAIM = 3), this represents the entity billing (or reporting) to the managed care plan (See PLAN-ID-NUMBER for reporting capitation plan-ID). Capitation PLAN-ID should be used in this field only for premium payments (TYPE-OF-SERVICE = 20, 21, 22,23)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

Note: Once a national provider ID numbering system is in place, the national number should be used.

If the State’s legacy ID number is also available then that number can be entered in this field.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: BILLING-PROV-SPECIALTY

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – This code describes the area of specialty for the BILLING PROVIDER

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “00”

Coding Requirements: Required

http://www.cms.hhs.gov/medicareprovidersupenroll/downloads/taxonomy.pdf

http://www.cms.hhs.gov/Transmittals/downloads/R1715CP.pdf

Valid Values Code Definition

01 General Practice

02 General Surgery

03 Allergy/Immunology

04 Otolaryngology

05 Anesthesiology

06 Cardiology

07 Dermatology

08 Family Practice

09 Interventional Pain Management

10 Gastroenterology

11 Internal Medicine

12 Osteopathic Manipulative Therapy

13 Neurology

14 Neurosurgery

16 Obstetrics/Gynecology

17 Hospice and Palliative Care

18 Ophthalmology

19 Oral Surgery (dentists only)

20 Orthopedic Surgery

21 Available

22 Pathology

23 Available

24 Plastic and Reconstructive Surgery

25 Physical Medicine and Rehabilitation

26 Psychiatry

27 Available

28 Colorectal Surgery (formerly proctology)

29 Pulmonary Disease

30 Diagnostic Radiology

CLAIMS FILES

31 Available

32 Anesthesiologist Assistants

33 Thoracic Surgery

34 Urology

35 Chiropractic

36 Nuclear Medicine

37 Pediatric Medicine

38 Geriatric Medicine

39 Nephrology

40 Hand Surgery

41 Optometry

44 Infectious Disease

46 Endocrinology

48 Podiatry

66 Rheumatology

70 Single or Multispecialty Clinic or Group Practice

72 Pain Management

73 Mass Immunization Roster Biller

74 Radiation Therapy Center

75 Slide Preparation Facilities

76 Peripheral Vascular Disease

77 Vascular Surgery

78 Cardiac Surgery

79 Addiction Medicine

81 Critical Care (Intensivists)

82 Hematology

83 Hematology/Oncology

84 Preventive Medicine

85 Maxillofacial Surgery

86 Neuropsychiatry

90 Medical Oncology

91 Surgical Oncology

92 Radiation Oncology

93 Emergency Medicine

94 Interventional Radiology

98 Gynecological/Oncology

99 Unknown Physician Specialty

A0 Hospital

A1 Skilled Nursing Facility

A2 Intermediate Care Nursing Facility

A3 Other Nursing Facility

A4 Home Health Agency

A5 Pharmacy

A6 Medical Supply Company with Respiratory Therapist

A7 Department Store

A8 Grocery Store

99 Unknown

Error Condition Resulting Error Code

Value is not in the list of valid values ???

2. Value is 9-filled 301

3. Value is “Space-filled” 303

4. Value is 0-filled 304

CLAIMS FILES

Data Element Name: BILLING-PROV-TAXONOMY

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX

For CLAIMOT files, the taxonomy code for the provider billing for the service.

For CLAIMIP and CLAIMLT files, the taxonomy code for the institution billing for the beneficiary.

For CLAIMRX files, the taxonomy code for the billing provider.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22,23)

Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.

http://www.wpc-edi.com/content/view/793/1

Error Condition Resulting Error Code

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1. Value is not in list of valid values ???

2. Value is 9-filled 301

3. Value is “Space-filled” 303

4. Value is 0-filled 304

5. Value = “888888888888" AND TYPE-OF-SERVICE <> {20, 21, 22,23} 305

6. Value <> “888888888888" AND TYPE-OF-SERVICE = {20, 21, 22,23} 306

CLAIMS FILES

Data Element Name: BILLING-PROV-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT - A code describing the type of entity billing for the service. For encounter records (TYPE-OF-SERVICE=3), This represents the entity billing (or reporting) to the Managed Care Plan (see PLAN-ID-NUMBER for reporting capitation plan-ID) CAPITATION-PLAN-ID should be used in this field only for premium payments (TYPE-OF-SERVICE=20,21,22,23)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 01

Coding Requirements: Required

Valid Values Code Definition

01 General Hospital

02 Special Hospital/Outpatient Rehabilitation Facility

03 Psychiatric Hospital

05 Community Mental Health Center

19 End Stage Renal Hospital

20 Pharmacy

25 Physician (MD)

26 Physician (DO)

27 Podiatrist

28 Chiropractor

29 Physician Assistant

30 Advanced Registered Nurse Practitioner (ARNP)

31 CRNA

32 Psychologist

34 Licensed Midwife

35 Dentist

36 Registered Nurse (RN)

37 Licensed Practical Nurse (LPN)

38 Nursing Attendant

39 Massage Therapist

40 Ambulance

41 Contract Nurse

42 Air/Water Ambulance Company

43 Taxi

44 Public Transportation

45 Private Transportation

46 Hospice

50 Independent Laboratory

51 Portable X-Ray Company

52 Alternative Medicine

53 Non-Medical Vendor

54 Prosthetics/Orthotics

55 Vocational Rehabilitation (Training, Tuition and Schools)

56 Vocational Rehabilitation Counselor

57 Rehabilitation Maintenance

58 Assisted Re-employment

59 Relocation Expenses

60 Audiologist/Speech Pathologist

61 Second Opinion Contractor

62 Optometrist

63 Optician

65 Home Health Agency

66 Rural Health Clinic

68 Federally Qualified Health Center

69 Birthing Center

70 HMO or PHP

71 Physical Therapist

72 Occupational Therapist

73 Pulmonary Rehabilitation

74 Outpatient Renal Dialysis Facility

75 Medical Supplies/Durable Medical Equipment (DME)

76 Case Management Agency

77 Social Worker

78 Blood Bank

79 Alternative Payee

80 Pay-to-Intermediary

88 Ambulatory Surgery Center

89 Federal Facility (VA Hospital)

90 Skilled Nursing Facility (SNF)-Medicare Certified

91 Skilled Nursing Facility (SNF)-Non-Medicare Certified

92 Intermediate Care Facility (ICF)

93 Rural Hospital Swing Bed

94 Boarding House

95 Insurance Company (Third Party Carriers)

96 Other Provider

97 Billing Agent

98 Lien holder

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: BILLING-UNIT

Definition: CLAIMLT - Unit of billing that is used for billing services by the facility.

Field Description:

COBOL PICTURE	Error Tolerance	Example Value

X(02)		‘01’

Coding Requirements:

	Valid Values	Code Definition
	01	Per Day
	02	Per Hour
	03	Per Case
	04	Per Encounter
	05	Per Week
	06	Per Month
	07	Other Arrangements
	99	Unknown

Error Condition

Resulting Error Code

1.	Value is 9-filled	301

CLAIMS FILES

Data Element Name: BIRTH-WEIGHT-GRAMS

Definition: CLAIMIP - The weight of a newborn at time of birth in grams.- Applicable to newborns only

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(4)v9 30375

Coding Requirements: Conditional

Required for a claim involving child birth.

Error Condition Resulting Error Code

1. Value = "99999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

Claims File

Data Element Name: BMI-CODE

Definition: Claims IP, LT & OT - A key index for relating a person's body weight to their height. The body mass index (BMI) is a person's weight in kilograms (kg) divided by their height in meters (m) squared.

SI units:

BMI = mass (kg) / (height(m))²

Imperial/US Customary units:

BMI = mass (lb) * 703/ (height(in))²

BMI = mass (lb) * 4.88/ (height(ft))²

BMI = mass (st) * 9840/ (height(in))²

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(02) 22

Error Condition Resulting Error Code

1. Value is Non-Numeric – 810

2. Value is 99 301

CLAIMS FILES

Data Element Name: BRAND-GENERIC-IND

Definition: CLAIMRX - Indicates whether the drug is a brand name, generic, single-source, or multi-source drug.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(01) 1

Coding Requirements: Required

Valid Values Code Definition

0 Non-Drug

1 Generic

2 Brand

3 Multi-Source

4 Single-Source.

Error Condition Resulting Error Code

1. Value = "9" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

Data Element Name: BORDER-STATE-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT and CLAIMRX - This code indicates for an individual receiving services or equipment across State borders.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) 0

Coding Requirements:

Valid Values Code Definition

0 No

1 Yes

Error Condition

Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: CHARGED-AMT

Definition: CLAIMLT, CLAIMOT, CLAIMRX - The amount charged at the claim detail level as submitted by the provider.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

If the amount is missing or invalid, fill with 0

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

CLAIMS FILES

Data Element Name: CHECK-EFFECTIVE-DATE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – Date the check is issued or Electronic Fund Transfer (EFT) effective date

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If date is not known, fill with 0

Could be the same as Remittance Date.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value is not a valid date - 102

3. Value > CHECK-EFFECTIVE-DATE. 517

CLAIMS FILES

Data Element Name: CHECK-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The check or EFT number.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(15) “111111111111111”

Coding Requirements:

When check is sent as EFT, the field contains nine ones and the document ID number.

If the number is missing or invalid, fill with 9999999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

CLAIM FILE

Data Element Name: CLAIM-DENIED-INDICATOR

Definition: An indicator to identify a claim that the state refused pay in its entirety.

Field Description:

COBOL Example

PICTURE Value

9(01) 0

Coding Requirements:

Valid Values Code Definition

Denied: The payment of claim in its entirety was denied by the state.
Not Denied: The state paid some or all of the claim.

It is expected that states will submit all denied claims to CMS..

Error Condition Resulting Error Code

1. Value is not in the valid values list 301

CLAIMS FILES

Data Element Name: CLAIM-LINE-COUNT

Definition: CLAIMLT, CLAIMIP, CLAIMOT, CLAIMRX - The total number of claim lines for: original -approved, pended and denied adjustment/debits and credits, the capitation payment and case management. The count used to identify the number of revenue center lines on a record/segment for determining the number of claims

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(04) 0045

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

CLAIMS FILES

Data Element Name: CLAIM-LINE-STATUS

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The health care claim line status codes convey the status of anana specific detail claim line rather than the entire claim or a specific service line.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(03) “123”

Coding Requirements: Conditional – Refer to APPENDIX D: Health Care Claim Status Codes

Source: http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 999 - 301

CLAIMS FILES

Data Element Name: CLAIM-PYMT-REM-CODE-1 THRU CLAIM-PYMT-REM-CODE-4

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(04) “N368”

Coding Requirements: Conditional – Refer to APPENDIX C: Remittance Advice Remark Codes

Error Condition Resulting Error Code

1. Value = "9999" 301

2. Value = “0000" 304

3. Value is “Space Filled” 303

4. Value <> "8888" AND SERVICE-CODE-FLAG = 88 306

CLAIMS FILES

Data Element Name: CLAIM-STATUS

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The health care claim status codes convey the status of an entire claim or a specific service line.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(03) “123”

Coding Requirements: Conditional – Refer to APPENDIX D: Health Care Claim Status Codes

Source: http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 999 - 301

CLAIMS FILES

Data Element Name: CLAIM-STATUS-CATEGORY

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The health care claim status category codes convey the category of the claim status or a specific service line.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(03) “123”

Coding Requirements: Conditional – Refer to code list below

Source: http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 999 - 301

CLAIMS FILES

Data Element Name: COMPOUND-DOSAGE-FORM

Definition: CLAIMRX – The physical form of a dose of medication, such as a capsule or injection.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “01”

Coding Requirements: Conditional

Valid Values Code Definition Valid Values Code Definition

01 Capsule 11 Solution

02 Ointment 12 Suspension

03 Cream 13 Lotion

04 Suppository 14 Shampoo

05 Powder 15 Elixir

06 Emulsion 16 Syrup

07 Liquid 17 Lozenge

10 Tablet 18 Enema

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: COMPOUND-DRUG-IND

Definition: CLAIMRX – Indicator to specify if the drug is compound or not.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) “1”

Coding Requirements: Conditional

Valid Values Code Definition

Not Compound
Compound

9 Unknown

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: COPAY-AMT

Definition: CLAIMOT, CLAIMRX - An amount paid by an enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by the insurance company.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

CLAIM FILE

Data Element Name: COPAY-WAIVED-IND

Definition: An indicator signifying that the copay was waived by the provider..

Field Description:

COBOL Example

PICTURE Value

9(01) 0

Coding Requirements:

Valid Values Code Definition

Waived: The provider waived the beneficiary’s copayment.
Not Waived: The provider did not waive the beneficiary’s copayment,

8 Not Applicable: The benefit plan does not have a copay in this circumstance.

Error Condition Resulting Error Code

1. Value is not in the valid values list ???

CLAIMS FILES

Data Element Name: CROSSOVER-INDICATOR

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X01 “1”

Coding Requirements: Required

Valid Values Code Definition

Not Crossover Claim
Crossover Claim

9 Unknown

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9 - 301

CLAIMS FILES

Data Element Name: DAILY-RATE

Definition: CLAIMLT, CLAIMOT - The amount a policy will pay per day for a covered service. In some cases for OT claims this is referred to as FLAT-RATE.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(05)V99 0012345

Coding Requirements: Required

Valid for outpatient and long term care only. Zero fill if unknown.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999- 301

CLAIM FILE

Data Element Name: DATE-CAPITATED-AMOUNT-REQUESTED

Definition: The date that the managed care entity submitted the capitated payment bill to the State..

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If it is unknown when the request was submitted, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

CLAIMS FILES

Data Element Name: DATE-PRESCRIBED

Definition: CLAIMRX - Date the drug, device or supply was prescribed by the physician or other practitioner. This should not be confused with the DATE-FILLED which represents the date the prescription was actually filled by the provider.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required

Value must be a valid date in CCYYMMDD format.

If date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value > PRESCRIPTION-FILL-DATE 535

CLAIMS FILES

Data Element Name: DAYS-SUPPLY

Definition: CLAIMRX - Number of days supply dispensed.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(03) 31

Coding Requirements: Required

Values should be greater than 1 and greater than-365.

If Value is unknown, 9-fill.

Error Condition Resulting Error Code

1. Value is Non-Numeric. 810

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2. Value = 999 - 301

3. Value = 0 or Value > 365 203

4. Value < 0 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

CLAIMS FILES

Data Element Name: DEDUCTIBLE-AMT

Definition: CLAIMIP, CLAIMOT, CLAIMRX - An amount paid each year by an enrollee before their health benefit begins

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

If the amount is missing or invalid, fill with 0

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

CLAIMS FILES

Data Element Name: DESTINATION-ADDR-LN1, LN2

Definition: CLAIMOT – The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(28) “123 Any Lane”

Coding Requirements: Conditional

For transportation claims only Required if State has captured this information, else conditional.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999999999999999999 - 301

CLAIMS FILES

Data Element Name: DESTINATION-CITY

Definition: CLAIMOT – The name of the destination city to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(28) “Any city”

Coding Requirements: Conditional

For transportation claims only Required if State has captured this information, else conditional.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999999999999999999 - 301

CLAIMS FILES

Data Element Name: DESTINATION-STATE

Definition: CLAIMOT – The FIPS state alpha for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “MD”

Coding Requirements: Conditional

For transportation claims only. Required if State has captured this information, else conditional.

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: DESTINATION-ZIP-CODE

Definition: CLAIMOT – The zip-code of the destination city to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(09) 21030

Coding Requirements: Conditional

For transportation claims only. Required if State has captured this information, else conditional.

Redefined as 9(05) and 9(04)

9(05) is needed

9(04) could be zero filled

If destination address is not filled could be zero filled.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: DIAGNOSIS-CODE (1 ) THRU DIAGNOSIS-CODE (12)

Definition: DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-2: CLAIMIP, CLAIMLT, CLAIMOT – Primary and Second ICD-9/10-CM code found on the claim.

DIAGNOSIS-CODE-3 through DIAGNOSIS-CODE-5: CLAIMIP, CLAIMLT - The third through fifth ICD-9/10-CM codes that appear on the claim.

DIAGNOSIS-CODE-6 through DIAGNOSIS-CODE-12: CLAIMIP- The sixth through twelfth ICD-9/10-CM codes that appear on the claim.

Field Description:

COBOL Example

PICTURE Value

X(08) “21050 "

Coding Requirements: Conditional

Code valid ICD-9/10‑CM codes without a decimal point. For example: 210.5 is coded as "2105 ".

The primary diagnosis code goes into DIAGNOSIS-CODE1.

If less than 12 diagnosis codes are used, blank fill the unused fields.

Enter invalid codes exactly as they appear in the State system. Do not “8-fill" or "9-fill" these items.

CLAIMOT: Code Specific ICD-9/10-CM code. There are many types of claims that aren’t expected to have diagnosis codes, such as transportation, DME, lab, etc. Do not add vague and unspecified diagnosis codes to those claims.

CLAIMLT: Provide diagnosis coding as submitted on bill.

8-fill if not applicable (i.e., the claim type does not allow for diagnoses codes).

9-fill if value is applicable, but unknown.

Note: Eighth character reserved for future expansion of this field.

Error Condition Resulting Error Code

Value is not in the list of valid values……………………………………………………………………???

2. Value= 9-filled………….………………………………………………………………………………….301

3. Value <> “blank” AND first character of Value is not {"0" through "9", or alpha character}……… 101

4. Value <> “blank” AND second or third character of Value is not {"0" through "9"}…………………..101

5. Value <> “blank” AND fourth or fifth character of Value is not " " or"0" through "9"}…………………101

6. Value <> “blank” AND fourth character of Value = " " AND fifth character of Value <> “ “ ………..101

7. Value <> “blank” AND sixth character of Value <> “ ”…………………………………………………...101

8. Value is blank ………………………………………………………………………………………………303

9. Value <> “blank” AND preceding DIAGNOSIS-CODE value(s) = “blank”......................................542

10. Value appears in preceding field…………………………………………………………………………...542

CLAIMS FILES

Data Element Name: DIAGNOSIS-CODE-FLAG (1 ) THRU DIAGNOSIS-CODE-FLAG (12)

Definition: CLAIMIP, CLAIMLT, CLAIMOT - A flag that identifies the coding system used for the DIAGNOSIS CODE 1 - 12.

DIAGNOSIS-CODE-FLAG-1 through DIAGNOSIS-CODE-FLAG-2: CLAIMIP, CLAIMLT, CLAIMOT – Code flag for the Primary and Second ICD-9/10-CM code found on the claim.

DIAGNOSIS-CODE-FLAG-3 through DIAGNOSIS-CODE-FLAG-5: CLAIMIP, CLAIMLT – Code flag for the third through fifth ICD-9/10-CM codes that appear on the claim.

DIAGNOSIS-CODE-FLAG-6 through DIAGNOSIS-CODE-FLAG-12: CLAIMIP- Code flag for the sixth through twelfth ICD-9/10-CM codes that appear on the claim.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 09

Coding Requirements: Required.

Valid Values Code Definition

01 ICD-9

02 ICD-10

03 Other

99 Unknown

Error Condition Resulting Error Code

Value is not numeric.

Value is not a valid value.

CLAIMS FILES

Data Element Name: DIAGNOSIS-POA-FLAG (1 ) THRU DIAGNOSIS-POA-FLAG (12)

Definition: CLAIMIP - A flag that indicates Present On Admission for DIAGNOSIS CODE 1 - 12.

A code to identify conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG) that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.

Field Description:

COBOL Example

PICTURE Value

X(01) Y

Coding Requirements: Required.

Valid Values Code Definition

Y Diagnosis was present at time of inpatient admission

N Diagnosis was not present at time of inpatient admission

U Documentation insufficient to determine if condition was present at the time of inpatient admission

W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

1 Exempt from POA reporting. This code is the equivalent of a blank on the UB-04.

BLANK Exempt from POA reporting.

NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting.

See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses.

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is “Y” but HEALTH-CARE-ACQUIRED-CONDITION-IND is 0 (No) or 9 (unknown) ………..???

Value is “N,” ”U,” ”W,” “1” or “BLANK”) but HEALTH-CARE-ACQUIRED-CONDITION-IND ……..

is 1 (Yes) or 1 (unknown) ???

CLAIMS FILES

Data Element Name: DIAGNOSIS-RELATED-GROUP

Definition: CLAIMIP - Code representing the Diagnosis Related Group (DRG) that is applicable for the inpatient services being rendered.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(04) 370

Coding Requirements: Conditional

Enter DRG used by the State.

If DRGs are not used, 8-fill the field.

If Value is unknown, 9-fill the field.

Error Condition Resulting Error Code

1. Value Not-Numeric - 810

2. Value = 8888 AND DIAGNOSIS-RELATED-GROUP-INDICATOR <> “8888" 540

3. Value = 9999 AND DIAGNOSIS-RELATED-GROUP-INDICATOR <> “9999" 540

4. Value <> 8888 AND Value 306

DIAGNOSIS-RELATED-GROUP-INDICATOR = “8888"

5. Value <> 9999 AND DIAGNOSIS-RELATED-GROUP-INDICATOR = “9999" 540

CLAIMS FILES

Data Element Name: DIAGNOSIS-RELATED-GROUP-IND

Definition: CLAIMIP - An indicator identifying the grouping algorithm used to assign DIAGNOSIS RELATED GROUP (DRG) values.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(04) “HG15”

Coding Requirements: Conditional

Values are generated by combining two types of information:

Position 1-2, State/Group generating DRG:

If state specific system, fill with two digit US postal code representation for state.

If CMS Grouper, fill with “HG”.

If any other system, fill with “XX”.

Position 3-4, fill with the number that represents the DRG version used (01-98). For example, “HG15" would represent CMS Grouper version 15. If version is unknown, fill with “99".

If no DRG system is used, fill the field with “8888".

If Value is unknown, fill the field with “9999".

Error Condition Resulting Error Code

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1. Value = “9999" 301

2. First and second characters of Value <> {“A” - “Z”} AND Value is NOT 8-Filled 101

3. Third and fourth characters of Value <> {“01" - “98"} AND first and second 101

Value = {“HG”} AND Value is NOT 8-Filled

CLAIMS FILES

Data Element Name: DISCHARGE-DATE

Definition: CLAIMIP, CLAIMLT - The date on which the recipient was discharged from a hospital or long term care facility.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Conditional

Value must be a valid date in CCYYMMDD format.

If discharge date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2. Value = 99999999 301

3. Value is not a valid date 102

4. Value CC <19 OR >20. Value is not a valid date. 102

5. Value > ENDING-DATE-OF-SERVICE 511

CLAIMS FILES

Data Element Name: DISCHARGE-HOUR

Definition: CLAIMIP, CLAIMLT - The time of discharge for inpatient claims or end time of treatment for outpatient claims.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(02) 23

Coding Requirements: Required

Value must be a valid hour in military time format (00 to 23).

If admission hour is not known, fill with 99.

Valid Values Code Definition Valid Values Code Definition

AM PM

00 0:00-0:59 12 12:00-12:59

01 1:00-1:59 13 13:00-13:59

02 2:00-2:59 14 14:00-14:59

03 3:00-3:59 15 15:00-15:59

04 4:00-4:59 16 16:00-16:59

05 5:00-5:59 17 17:00-17:59

06 6:00-6:59 18 18:00-18:59

07 7:00-7:59 19 19:00-19:59

08 8:00-8:59 20 20:00-20:59

09 9:00-9:59 21 21:00-21:59

10 10:00-10:59 22 22:00-22:59

11 11:00-11:59 23 23:00-23:59

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: DISPENSE-FEE

Definition: CLAIMRX – The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(06)V99 0002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “0002002E”.

The actual value of -200.25 will be stored as the value of “0002002N”.

Coding Requirements: Required.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

CLAIMS FILES

Data Element Name: DRG-DESCRIPTION

Definition: CLAIMIP– Description of the associated STATE Specific DRG code.

If using standard MS-DRG classification system, leave blank.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(20) “CRANIOTOMY AGE >17 W CC”

Coding Requirements: Conditional

Source: http://edocket.access.gpo.gov/2009/pdf/E9-12907.pdf

http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/DRGdesc06.pdf

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999999999999999999 - 301

CLAIMS FILES

Data Element Name: DRG-OUTLIER-AMT

Definition: CLAIMIP – Outlier payments compensate hospitals paid on a fixed amount per Medicare "diagnosis related group" discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category. This data element captures the additional payment associated either a cost outlier or Length of Stay outlier.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 00012345

Coding Requirements: Conditional

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

CLAIMS FILES

Data Element Name: DRG-REL-WEIGHT

Definition: CLAIMIP - Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 1.0234

Coding Requirements: Conditional.

State Specific.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 - 301

CLAIMS FILES

Data Element Name: DRUG-UTILIZATION-CODE

Definition: CLAIMRX– A DUR response consists of three components. The conflict code is a two-digit entry that contains the same two letters of the alert that the pharmacist wants to override. The intervention code describes what action the pharmacist took - whether he or she consulted the prescriber (M0), the patient (P0) or another source (R0), including the provider's own knowledge. Finally, the outcome code describes the intended outcome of the claim. This includes a number of codes that show the prescription was filled (1A through 1G) and two codes showing the prescription was not filled (2A and 2B).

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “2B”

Coding Requirements: Required

Valid Values Code Definition

Conflict Codes

HD High dose

PA Drug-age conflict

LD Low dose

PG Drug-pregnancy conflict

LR Underutilization - late refill

SX Drug-gender conflict

DA Drug-allergy conflict

MX Incorrect duration

ER Overutilization - early refill, same pharmacy only

TD Therapeutic duplication, same pharmacy only

ID Ingredient duplication, same pharmacy only

Intervention Codes

M0 Consulted the prescriber

P0 Consulted the patient

R0 Consulted another source

Output codes

1A Filled, False Positive

1B Filled prescription as is

1C Filled with different dose

1D Filled with different directions

1E Filled with different drug

1F Filled with different quantity

1G Filled with prescriber approval

2A Prescription not filled

2B Prescription not filled – directions clarified

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999 - 301

CLAIMS FILES

Data Element Name: DTL-METRIC-DEC-QTY

Definition: CLAIMRX– Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter.)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(07)V999 000002.500

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999 - 301

CLAIMS FILES

Data Element Name: ENDING-DATE-OF-SERVICE

Definition: CLAIMIP, CLAIMLT, CLAIMOT - For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required

Date format is CCYYMMDD (National Data Standard).

If date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value > END-OF-TIME-PERIOD in the Header Record 605

AND TYPE-OF-SERVICE <> {20, 21, 22, 23}

5. Value < BEGINNING-DATE-OF-SERVICE. 511

CLAIMS FILES

Data Element Name: FIXED-PAYMENT-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management (PCCM) programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment.

It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined “medical record” associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) ‘0’

Coding Requirements:

Valid Values Code Definition

0 Not Fixed Payment

1 FFS Fixed Payment

2 Managed Care

Error Condition Resulting Error Code

Value is not numeric.

Value is not a valid value.

CLAIMS FILES

Data Element Name: FORCED-CLAIM-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT and CLAIMRX - This code indicates if the claim was processed by forcing it through a manual override process,

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) 0

Coding Requirements:

Valid Values Code Definition

0 No

1 Yes

Error Condition

Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: FUNDING-CODE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The funding code is related to what account the payment was made. This code indicates if the claim was matched with Title XIX, Title XXI, local funds or other funding source or Code that identifies the source of funds to be paid to a provider for a particular service. Codes will be state specific and will be identified by the state.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) 3

Coding Requirements:

Valid Values Code Definition

1 Medicaid

2 CHIP

3 Mental Health Services

4 FEQH

5 State Schools

6 Child and Family Services

7 Local State Services

8 Buy-ins

9 Psychiatric Residential Treatment facilities

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: FUNDING-SOURCE-STATE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX –

FIPS state alpha for each U.S. state, Territory, and the District of Columbia that provides the funding source.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 15

Coding Requirements:

Valid Values Code Definition

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: HCBS-SERVICE-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT – This is a flag indicating whether the service was received through the HCBS Waiver.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) 1

Coding Requirements: Required.

Valid Values Code Definition

1 Yes

9 Unknown

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: HEALTH-CARE-ACQUIRED-CONDITION-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT and, CLAIMRX – This code indicates whether the claim has a Health Care Acquired Condition

Field Description:

COBOL Example

PICTURE Value

X(01) 1

Coding Requirements: Required.

For additional coding information refer to the following site

https://www.cms.gov/hospitalacqcond/05_Coding.asp#TopOfPage

Valid Values Code Definition

0 No

1 Yes

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is “0” but DIAGNOSIS-POA-FLAG is “Y”……..…………………………...…………… ……..???

Value is “1” or “9” but DIAGNOSIS-POA-FLAG is “N,” ”U,” ”W,” “1” or “BLANK” ……………..…..???

4. Value is 9-filled 301

CLAIM FILE

Data Element Name: HEALTH-HOME-ENTITY-NAME

Definition: A free-form text field on claim header records for the name of the health home team to which the provider belongs for purposes of treating the patient. The name entered should be the name that the state uses to uniquely identify the team. A “Health Home Entity” can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals).

Field Description:

COBOL Example

PICTURE Value

X(100) Coordinated Care Associates, LLC.

Coding Requirements:

The HEALTH-HOME-ENTITY-NAME field must be populated whenever the HEALTH-HOME-PROVIDER-IND on the claim header record is set to “Yes.”

Valid characters in the text string are limited to alpha characters (A-Z, a-z), numbers (0-9), dashes (“-“), commas (“,”), and periods (“.”).

Error Condition Resulting Error Code

1. The HEALTH-HOME-ENTITY-NAME field is empty even though the HEALTH-HOME-PROVIDER-IND field is set to “Yes.” ???

2. The text string contains invalid characters ???

CLAIMS FILES

Data Element Name: HEALTH-HOME-PROVIDER-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT,CLAIMRX – This code indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) 9

Coding Requirements: Required.

If a State has not yet begun collecting this information, HEALTH-HOME-PROVIDER-IND, then this field should be defaulted to the value “8.”

Valid Values Code Definition

0 No

1 Yes

8 Unavailable

9 Unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value is 9-filled 301

CLAIMS FILES

Data Element Name: ICF-MR-DAYS

Definition: CLAIMLT - The number of days of intermediate care for the mentally retarded should be included in this claim, that were paid for, in whole or in part, by Medicaid.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(05) 14

Coding Requirements: Conditional

ICF-MR-DAYS include every day of intermediate care facility services for the mentally retarded that is at least partially paid for by the State, even if private or third party funds are used for some portion of the payment.

If value exceeds +99998 days, code as +99998. (e.g., code 100023 as +99998)

ICF-MR-DAYS is applicable only for TYPE-OF-SERVICE = 05.

For all claims for psychiatric services or nursing facility care services (TYPE-OF-SERVICE = 02, 04, or 07), fill with +88888.

If value is not known or invalid, fill with +99999.

Error Condition Resulting Error Code

1. Value is Non-Numeric OR Value = -88888…………………………………………..810

2. Value = +99999 - ……………………………………………………………………………….301

3. Value <> +88888 AND TYPE-OF-SERVICE = {02, 04, or 07}…………………………………………306

4. Value = +88888 AND TYPE-OF-SERVICE = {05}………………………………………………………305

5. Value > +00000 AND NURSING-FACILITY-DAYS > +0……………………………………………….508

6. Value > (ENDING-DATE-OF-SERVICE - BEGINNING-DATE OF-SERVICE) + 1................603

7. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4}………………………………………...607

8. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3}…………………………………………….607

CLAIMS FILES

Data Element Name: ICN-ADJ

Definition: CLAIMIP, CLAIMLT, CLAIMOT and CLAIMRX - A unique claim number (up to 21 alpha/numeric characters) assigned by the State’s payment system that identifies the adjustment claim for an original transaction.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(21) “ABC111222333444555666”

Coding Requirements: Required

Record the value exactly as it appears in the State system. Do not pad.

This field should be 8-filled if the ADJUSTMENT-INDICATOR = 0

If Value is unknown, fill with "999999999999999999999".

Error Condition Resulting Error Code

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE

FOR GROSS ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=5)

1. Value = "999999999999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “888888888888888888888" AND ADJUSTMENT-INDICATOR IS NE 0 305

CLAIMS FILES

Data Element Name: ICN-ORIG

Definition: CLAIMIP, CLAIMLT, CLAIMOT and CLAIMRX - A unique number (up to 21 alpha/numeric characters) assigned by the State’s payment system that identifies an original claim.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(21) “ABC000111222333444555666”

Coding Requirements: Required

Record the value exactly as it appears in the State system. Do not pad.

If the ADJUSTMENT-INDICATOR is ‘0’ then this field must include the ICN for the original claim. On adjustment claims this field should show the ICN for the claim being adjusted.

If Value is unknown, or the claim is a service tracking claim, fill with "999999999999999999999".

Error Condition Resulting Error Code

1. Value = "999999999999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: IMMUNIZATION-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT,CLAIMRX – Tracks additional detail not currently contained in CPT codes. This field identifies the type of immunization provided.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 09

Coding Requirements: Required.

Valid Values Code Definition

00 None

01 Anthrax

02 Cervical Cancer)

03 Diphtheria

04 Hepatitis A

05 Hepatitis B

06 Haemophilus influenza type b (Hib)

07 Human Papillomavirus (HPV)

08 H1N1 Flu

09 Seasonal Flu

10 Japanese Encephalitis

11 Lyme Disease

12 Measles

13 Meningococcal

14 Monkey pox

15 Mumps

16 Pertussis

17 Pneumococcal

18 Poliomyelitis

19 Rabies

20 Rotavirus

21 Rubella

22 Shingles

23 Smallpox

24 Tetanus

25 Tuberculosis

26 Typhoid Fever

27 Varicella

28 Yellow Fever

88 Other

99 Unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value is 9-filled ???

CLAIMS FILES

Data Element Name: LEAVE-DAYS

Definition: CLAIMLT - The number of days, during the period covered by Medicaid, on which the patient did not reside in the long term care facility.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(05) 00056

Coding Requirements: Conditional

LEAVE-DAYS is applicable only for TYPE-OF-SERVICE = 05 or 07.

If invalid/na fill with 0.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999 - 301

3. Value > 0 AND > NURSING-FACILITY-DAYS AND

TYPE-OF-SERVICE = 07 508

4. Value > 0 AND > ICF-MR-DAYS AND

TYPE-OF-SERVICE = 05 608

5. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

6. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: LINE-NUM-ADJ

Definition: CLAIMOT,CLAIMLT, CLAIMIP, CLAIMRX - A unique number to identify the transaction line number that identifies the line number on the adjustment ICN.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(03) 001

Coding Requirements: Required

Record the value exactly as it appears in the State system. Do not pad.

This field should be 8-filled if the ADJUSTMENT-INDICATOR = 0.

Error Condition Resulting Error Code

1. Value = 999 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = 888 AND ADJUSTMENT-INDICATOR IS NE 0 306

CLAIMS FILES

Data Element Name: LINE-NUM-ORIG

Definition: CLAIMLT, CLAIMIP, CLAIMOT, CLAIMRX - A unique number to identify the transaction line number that is being reported on the original claim.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(03) 001

Coding Requirements: Required.

Record the value exactly as it appears in the State system. Do not pad. This field should also be completed on adjustment claims to reflect the LINE-NUMBER of the INTERNAL-CONTROL-NUMBER on the claim that is being adjusted.

Error Condition Resulting Error Code

1. Value = "999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “888" AND ADJUSTMENT-INDICATOR IS = 0 305

CLAIMS FILES

Data Element Name: LTC-RCP-LIAB-AMT

Definition: CLAIMLT, The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If amount is missing or invalid, fill with 0

If TYPE-OF-CLAIM = 3 (encounter record) and no funds were used, fill with 0000000.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value > AMOUNT-CHARGED-MEDICAID MINUS .....................................................................704

(MEDICARE COINSURANCE-PAYMENT + MEDICARE-DEDUCTIBLE-PAYMENT)

3. Value < 0000000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

4. Value > 0000000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIM FILE

Data Element Name: MEDICAID-AMOUNT-PAID-DSH

Definition: The amount included in the TOT-MEDICAID-PAID-AMT that is attributable to a Disproportionate Share Hospital (DSH) payment, when the state makes DSH payments by claim.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If the field is not applicable, enter all 8s..

If the field is applicable, but the amount is unknown, enter all 9s.

Valid Values Code Definition

S9(11)V99 000000002002E

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = "999999999999" 301

CLAIMS FILES

Data Element Name: MEDICAID‑COV-INPATIENT-DAYS

Definition: CLAIMIP, CLAIMLT

CLAIMIP - The number of inpatient days covered by Medicaid on this claim. For states that combine delivery/birth services on a single claim, include covered days for both the mother and the neonate in this field.

CLAIMLT - The number of inpatient psychiatric days covered by Medicaid on this claim.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(05) 30

Coding Requirements: Required.

This field is applicable when:

- A CLAIMIP record includes at least one accommodation revenue code = (values 100-219) in UB-REV-CODE-(1-23) fields.

- A CLAIMLT record has TYPE-OF-SERVICE = 02 or 04 (inpatient mental health/psychiatric services).

When this field is not applicable, fill with +88888.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = +99999 - 301

3. Value <> +88888 AND TYPE-OF-SERVICE = {05 or 07} 306

4. Value =+88888 AND TYPE-OF-SERVICE = {02 or 04} 305

5. Value > (ENDING-DATE-OF-SERVICE - BEGINNING-DATE-OF- 603

SERVICE + 1 (in days))X2

6. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

7. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: MEDICAID-FFS-EQUIVALENT-AMT

Definition: CLAIMLT, CLAIMIP, CLAIMOT, CLAIMRX - The Fee-For-Service equivalent value of a capitated encounter .

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

For TYPE-OF-CLAIM = 3 (encounter).

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

CLAIMS FILES

Data Element Name: MEDICAID-PAID-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicaid on this claim or adjustment at the claim detail level.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

If invalid or unknown, fill with +0.

TYPE-OF-CLAIM = 3 (encounter): If MEDICAID had no liability for the bill, 0-fill. Amount Paid should reflect the actual amount paid by Medicaid. It is not intended to reflect fee-for-service equivalents, we have a separate field for that: MEDICAID-FFS-EQUIVALENT-AMT. If the claim contains the amount paid to a provider by a plan, please put that payment to the AMOUNT CHARGED field.

For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim.

For service tracking payments, 0 fill and provide payment amount in SERVICE-TRACKING-PAYMENT-AMT.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2 Value < +00000000 AND ADJUSTMENT-INDICATOR = {0, 2 or 4} 607

3 Value > +00000000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: MEDICAID-PAID-DATE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The date Medicaid paid on this claim or adjustment.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required

Value must be a valid date in CCYYMMDD format.

If date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 301

3. Value is not a valid date 102

CLAIMS FILES

Data Element Name: MEDICARE-COINS-AMT

Definition: CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicaid/CHIP, on this claim, toward the recipient's Medicare coinsurance at the claim detail level.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

This field is relevant only for Crossover (Medicare is third party payee) claims. Crossover claims with coinsurance can only occur when TYPE-OF-SERVICE = (01, 02, 04, 07, 08, 10 through 12, 15, 19, 24 through 26, 30, 31, 33 through 39).If claim is not a Crossover claim, fill with +0.

If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field.If Medicare coinsurance and deductible payments cannot be separated, fill this field with +99998 and code the combined payment amount in MEDICARE-DEDUCTIBLE-PAYMENT.

For Crossover claims with no coinsurance payment, fill with +00000. For Crossover claims with missing or invalid coinsurance amounts, fill with +99999. For TYPE-OF-CLAIM = 3 (encounter record) fill with +88888.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = -88888

2. Value = +99999 - 301

3. Value <> +88888 AND (MEDICARE-DEDUCTIBLE-PAYMENT = 306

+88888 OR TYPE-OF=SERVICE = 13 OR TYPE-OF-CLAIM = 3)

4. Value = +99998 AND MEDICARE-DEDUCTIBLE-AMOUNT = (+0, +999998) 515

5. Value > AMOUNT-CHARGED 606

6. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

7. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: MEDICARE-DEDUCTIBLE-AMT

Definition: CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicaid/CHIP, on this claim, toward the recipient's Medicare deductible.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

This field is relevant only for Crossover (when Medicare is the third party payee) claims. Crossover claims with deductibles can only occur when TYPE-OF-SERVICE = {01, 02, 04, 08, 10 through 13, 15, 19, 24 through 26, 30, 31, 33 through 39). If claim is not a Crossover claim, or if a type of claim 3 (encounter claim) fill with +0.

If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field.If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount and code 1 MEDICARE-COMB-DED-IND.

For Crossover claims with no Medicare deductible payment, fill this field with +00000.

For Crossover claims with missing or invalid deductible amounts, fill this field with +0.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

OR Value = -88888

2. Value = +99999 301

3. Value <> +88888 AND VALUE<> +00000 AND TYPE-OF=SERVICE = {05 or 07} 306

4. Value > AMOUNT-CHARGED 510

5. Value < +00000 AND ADJUSTMENT -INDICATOR = {0, 2, or 4} 607

6. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

Data Element Name: MEDICARE-COMB-DED-IND

Definition: CLAIMLT, CLAIMIP, CLAIMOT, CLAIMRX – Code indicating that the amount paid by Medicaid/CHIP, on this claim, toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) “1”

Coding Requirements: Required.

If claim is not a Crossover claim, or if a type of claim 3 (encounter claim) fill with +0.

0 = Amount not combined with coinsurance amount

1 = Amount combined with coinsurance amount

9 = Unknown

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value is not in valid set - 301

CLAIMS FILES

Data Element Name: MEDICARE-HIC-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - Health Insurance Claim (HIC) Number as it appears on the patient’s Medicare card.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) 123456789A12

Coding Requirements: Conditional

If invalid or unknown, fill with 999999999.

"Railroad Retirees" - Railroad Retirement Board (RRB) HIC numbers generally have two alpha characters as a prefix to the number.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = +99999999 - 301

3. Value < +00000000 AND ADJUSTMENT-INDICATOR = {0, 2 or 4} 607

4. Value > +00000000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: MEDICARE-PAID-AMT

Definition: CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicare on this claim or adjustment.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

If invalid or unknown, fill with +99999999.

TYPE-OF-CLAIM = 3 (encounter): If MEDICARE had no liability for the bill, 0-fill. Amount Paid should reflect the actual amount paid by Medicare. It is not intended to reflect fee-for-service equivalents, we have a separate field for that. If the claim contains the amount paid to a provider by a plan, please put that payment to the CHARGED_AMT field.

For claims where Medicare payment is only available at the header level, report the entire payment amount the MSIS record corresponding to the line item with the highest charge. Zero fill Medicare Amount Paid on all other MSIS records created from the original claim.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = +99999999 - 301

3. Value < +00000000 AND ADJUSTMENT-INDICATOR = {0, 2 or 4} 607

4. Value > +00000000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: MEDICARE-REIM-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT,CLAIMRX – This code indicates the type of Medicare Reimbursement.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) 9

Coding Requirements: Required.

Valid values to be provided.

Error Condition Resulting Error Code

Value is not a valid value.

CLAIMS FILES

Data Element Name: MSIS-IDENTIFICATION-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A unique identification number used to identify a Medicaid Eligible to MSIS.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(20) 123456789

Coding Requirements: Required.

For SSN States, this field must contain the Eligible's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number.

For non-SSN States, this field must contain an identification number assigned by the State. The format of the State ID numbers must be supplied to CMS.

For lump sum adjustments, this field must begin with an ‘&’.

Error Condition Resulting Error Code

1. Value is "Space Filled" 303

2. Value = all 9's 301

3. Value = all 0's 304

4. Value is 8-filled 305

5. Duplicate Claim Record - 100% match of all fields AND TYPE-OF-SERVICE<>09,11,13, OR 25 803

CLAIMS FILES

Data Element Name: NATIONAL-DRUG-CODE

Definition: CLAIMOT, CLAIMRX - A code indicating the drug, device or medical supply covered by this claim, in National Drug Code (NDC) format.

NATIONAL-DRUG-CODE: CLAIMRX

NATIONAL-DRUG-CODE-1 through NATIONAL-DRUG-CODE-5: CLAIMOT

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(11) 00039001460

Coding Requirements: Required

This field is applicable only for TYPE-OF-SERVICE = 16 or 19.

Drug code formats must be supplied by State in advance of submitting any file data. States must inform CMS of the NDC segments used and their size (e.g., {5,4,2} or {5,4} as defined in the National Drug Code Directory).

If the Drug Code is less than 12 characters in length, the value must be left justified and padded with spaces.

If Durable Medical Equipment or supply is prescribed by a physician and provided by a pharmacy then HCPCS or state specific codes can be put in the NDC field.

Error Condition Resulting Error Code

1. Value = 9-filled 301

2. Value = 0-filled 304

3. Value is “Space Filled” 303

4. Value is invalid AND TYPE-OF-SERVICE=16 203

Position 1-5 must be Numeric

Position 6-9 must be Alpha Numeric,

Position 10-11 must be Alpha Numeric or blank,

Position 12 must be blank

CLAIMS FILES

Data Element Name: NEW-REFILL-IND

Definition: CLAIMRX - Indicator showing whether the prescription being filled was a new prescription or a refill. If it is a refill, the indicator will indicate the number of refills.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(02) 00

Coding Requirements: Conditional.

00 = New Prescription

01-98 = Number of Refill

99 = Unknown

Error Condition

Resulting Error Code

1. Value is Non-Numeric - 812

2. Value = 99 AND NATIONAL-DRUG-CODE <> “999999999999" 536

3. Value = 99 301

CLAIMS FILES

Data Element Name: NON-COV-CHARGES

Definition: CLAIMIP, CLAIMLT - The charges which are not reimbursable by the primary payer.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Conditional.

The amount must be entered in dollars and cents.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = +99999999 - 301

CLAIMS FILES

Data Element Name: NON-COV-DAYS

Definition: CLAIMIP, CLAIMLT - The number of days not covered by the payer for this sequence as qualified by the payer organization.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(03) 3

Coding Requirements: Conditional.

Must contain number of non-covered days.

The sum of Non-Covered Days and Covered Days must not exceed Total Length of Stay (Statement Covers Period - Thru Date minus Admission Date\Start of Care) for any payer sequence.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999 - 301

CLAIMS FILES

Data Element Name: NURSING-FACILITY-DAYS

Definition: CLAIMLT - The number of days of nursing care included in this claim that were paid for, in whole or in part, by Medicaid. Includes days during which nursing facility received partial payment for holding a bed during patient leave days.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(05) 14

Coding Requirements: Required.

NURSING-FACILITY-DAYS include every day of nursing care services that is at least partially paid for by the State, even if private or third party funds are used for some portion of the payment.

If value exceeds +99998 days, code as +99998.

NURSING-FACILITY-DAYS is applicable only for TYPE-OF-SERVICE = 07.

For all claims for psychiatric services or intermediate care services for mentally retarded (TYPE-OF-SERVICE = 02, 04, or 05), fill with +88888.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = -88888

2. Value =+99999 - 301

3. Value <> +88888 AND TYPE-OF-SERVICE = {02, 04, or 05} 306

4. Value =+88888 AND TYPE-OF-SERVICE = {07} 305

5. Value > (ENDING-DATE-OF-SERVICE - 603

BEGINNING-DATE-OF-SERVICE + 1)

6. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

7. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: OCCURRENCE-CODE

Definition: CLAIMIP, CLAIMLT, CLAIMOT - Code indicating type of accident record claim/encounter represents.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “01”

Coding Requirements: Required

Valid Values Code Definition

00 Not an accident

01 Auto accident - The date of an auto accident.

02 No-fault insurance involved, including auto accident/other - The date of an accident where the state has applicable no-fault liability laws, (i.e., legal basis for settlement without admission or proof of guilt).

03 Accident/tort liability - The date of an accident resulting from a third party's action that may involve a civil court process in an attempt to require payment by the third party, other than no-fault liability.

04 Accident/employment related - The date of an accident relating to the patient's employment.

05 Accident/No Medical or Liability Coverage - Code indicating accident related injury for which there is no medical payment or third-party liability coverage. Provide date of accident or injury.

06 Crime Victim - Code indicating the date on which a medical condition resulted from alleged criminal action committed by one or more parties.

24 Date Insurance Denied - Date of receipt of a denial of coverage by a higher priority payer.

25 Date Benefits Terminated by Primary Payer - The date on which coverage (including Worker’s Compensation benefits or no-fault coverage) is no longer available to the patient.

71 Hospital Prior Stay Dates - (Part A claims only.) The From/Through dates given by the patient of any hospital stay that ended within 60 days of this hospital or SNF admission.

74 Non-covered Level of Care - The From/Through dates for a period at a non-covered level of care in an otherwise covered stay, excluding any period reported with occurrence span codes 76, 77, or 79. Codes 76 and 77 apply to most non-covered care. Used for leave of absence, or for repetitive Part B services to show a period of inpatient hospital care or outpatient surgery during the billing period. Also used for HHA or hospice services billed under Part A, but not valid for HHA under PPS.

A3 Benefits Exhausted - The last date for which benefits are available and after which no payment can be made by payer A.

B3 Benefits Exhausted - The last date for which benefits are available and after which no payment can be made by payer B.

C3 Benefits Exhausted - The last date for which benefits are available and after which no payment can be made by payer C.

DR Reserved for Disaster Related Code.

MR Reserved for Disaster Related Code.

99 Unknown

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: OPERATING-PROV-NPI-NUM

Definition: CLAIMIP, CLAIMOT – The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary

Field Description:

COBOL Example

PICTURE Value

X(10) “1234567890”

Coding Requirements: Required.

If claim/encounter record is for non-surgical services, 8-fill the field.

If Value is applicable but unknown, fill with "9999999999".

Error Condition Resulting Error Code

1. Value = "9999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: ORIGINATION-ADDR-LN1, LN2

Definition: CLAIMOT – The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(28) “123 Any Lane”

Coding Requirements: Conditional

For transportation claims only Required if State has captured this information, else conditional.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999999999999999999 301

CLAIMS FILES

Data Element Name: ORIGINATION-CITY

Definition: CLAIMOT – The name of the origination city from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(28) “Any city”

Coding Requirements: Conditional

For transportation claims only Required if State has captured this information, else conditional.

Error Condition Resulting Error Code

1. Value is Numeric 810

2. Value = 9999999999999999999999999999 301

CLAIMS FILES

Data Element Name: ORIGINATION-STATE

Definition: CLAIMOT – The two letter abbreviation of the origination state in which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “MD”

Coding Requirements: Conditional

Valid two letter State Abbreviation.

For transportation claims only Required if State has captured this information, else conditional.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 - 301

CLAIMS FILES

Data Element Name: ORIGINATION-ZIP-CODE

Definition: CLAIMOT – The zip-code of the origination city from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(09) 210300000

Coding Requirements: Conditional

For transportation claims only Required if State has captured this information, else conditional.

Redefined as 9(05) and 9(04)

9(05) is needed

9(04) could be zero filled

If origination address is not filled could be 9 filled.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9 filled - 301

CLAIMS FILES

Data Element Name: OTHER-COINS-AMT

Definition: CLAIMLT, CLAIMIP, CLAIMOT, CLAIMRX – The amount paid by insurance other than Medicare or Medicaid, on this claim,.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9 filled - 301

CLAIMS FILES

Data Element Name: OTHER-INSURANCE-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The field denotes whether the insured party is covered under other insurance plan.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) 1

Coding Requirements: Required

Valid Values Code Definition

1 Yes

0 No

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 301

CLAIMS FILES

Data Element Name: OTHER-TPL-COLLECTION

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary.

Field Description:

COBOL Example

PICTURE Value

9(03) “001”

Coding Requirements: Required.

Valid Values Code Definition

000 Not Applicable

001 Third Party Resource is Casualty/Tort

002 Third Party Resource is Estate

003 Third Party Resource is Lien (TEFRA)

004 Third Party Resource is Lien (Other)

005 Third Party Resource is Worker’s Compensation

006 Third Party Resource is Medical Malpractice

007 Third Party Resource is Other

999 Classification of Third Party Resource is Unknown

Error Condition Resulting Error Code

1. Value = "999" 301

2. Value is not in the valid values list 303

CLAIMS FILES

Data Element Name: OUTLIER-CODE

Definition: CLAIMIP – This code indicates the Type of Outlier Code or DRG Source.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 09

Coding Requirements: Required.

Valid Values Code Definition

No Outlier
Day Outlier
Cost Outlier

6 Valid DRG Received from the intermediary

7 CMS Developed DRG

8 CMS Developed DRG Using Patient Status Code

9 Not Group able

10 Composite of cost outliers

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99 301

CLAIMS FILES

Data Element Name: OUTLIER-DAYS

Definition: CLAIMIP - This field specifies the number of days paid as outliers under pediatric preventive services (PPS) and the days over the threshold for the DRG.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(03) 365

Coding Requirements: Conditional.

Used in conjunction with OUTLIER-CODE field. The field identifies two mutually exclusive conditions. The first, for pps providers (codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-pps providers (codes 6, 7, 8, and 9), denotes the source for developing the DRG.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999 301

CLAIMS FILES

Data Element Name: PATIENT-CONTROL-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client’s episode of service within the provider’s system to facilitate retrieval of individual financial and clinical records and posting of payment.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(20) A1234567B89

Coding Requirements: Conditional.

If not known leave blank.

Must be numeric (0-9) and/or alphabetic (A-Z). Special characters are invalid entries

Error Condition Resulting Error Code

1. Value = 9999999999 301

CLAIMS FILES

Data Element Name: PATIENT-DATE-OF-BIRTH

Definition: CLAIMIP CLAIMLT CLAIMOT CLAIMRX - Date of birth of the patient.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 01012009

Coding Requirements: Conditional.

The patient’s date of birth shall be reported in numeric form as follows – 2 digit month, 2 digit day, and 4 digit year.

The numeric form for days and months from 1 to 9 must have a zero as the first digit.

Use Expected Date of Birth for unborn child.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999 301

CLAIMS FILE

Data Element Name: PATIENT-FIRST-NAME

Definition: CLAIMIP CLAIMLT CLAIMOT CLAIMRX - The first name of the individual to whom the services were provided.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “Mickey”

Coding Requirements: Conditional.

Error Condition Resulting Error Code

1. Value is Numeric 810

2. Value = 9 filled 301

CLAIMS FILE

Data Element Name: PATIENT-LAST-NAME

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The last name of the individual to whom the services were provided.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(17) “Mouse”

Coding Requirements: Conditional.

Error Condition Resulting Error Code

1. Value is Numeric 810

2. Value = 9 filled 301

CLAIMS FILE

Data Element Name: PATIENT-MIDDLE-INIT

Definition: CLAIMIP CLAIMLT CLAIMOT CLAIMRX - The middle initial of the individual to whom the services were provided.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) “R”

Coding Requirements:

Leave blank if not available

Error Condition Resulting Error Code

1. Value is Numeric 810

2. Value = 9 301

CLAIMS FILE

Data Element Name: PATIENT-STATUS

Definition: CLAIMIP, CLAIMLT - A code indicating the Patients status as of the ENDING-DATE-OF-SERVICE. Values used are from UB-92/UB-04. This is also referred to as DISCHARGE-STATUS.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 05

Coding Requirements: Required.

Source: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0801.pdf

Valid Values Code Definition

01 Discharged to home or self care (routine discharge)

02 Discharged/transferred to another short-term general hospital

03 Discharged/transferred to NF

04 Discharged/transferred to an ICF

05 Discharged/transferred to another type of institution (including distinct parts) or referred for outpatient services to another institution

06 Discharged/transferred to home under care of organized home health service organization

07 Left against medical advice or discontinued care

08 Discharged/transferred to home under care of a home IV drug therapy provider

09 Admitted as an inpatient to this hospital

20 Expired

30 Still a patient

40 Expired at home

41 Expired in a medical facility such as a hospital, NF or freestanding hospice

42 Expired - place unknown

43 Discharged/transferred to a Federal hospital (effective 10/1/03)

50 Discharged home with Hospice care

51 Discharged to a medical facility with Hospice care

61 Discharged to a hospital-based Medicare approved swing bed

62 Discharged/transferred to another rehab facility/rehab unit of a hospital

63 Discharged/transferred to a long term care hospital

65 Discharged/transferred to a psych hospital/psych unit of a hospital (effective 4/1/04)

66 Discharged to Critical Access Hospital

71 Discharged/transferred to another institution for outpatient services (deleted as of 10/1/03)

72 Discharged/transferred to this institution for outpatient services (deleted as of 10/1/03)

99 Unknown

Error Condition

Resulting Error Code

1. Value is Non-Numeric - 812

2. Value = 99 301

3. Value < 01 OR Value > 72 203

4. Value = {10-19, 21-29, 31-39, 44-49, 52-60, 64, 67-70, 73-98} 201

CLAIMS FILE

Data Element Name: PAYMENT-LEVEL-IND

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The field denotes whether the claim payment is made at the header level or the detail level.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(01) 01

Coding Requirements: Required.

Valid Values Code Definition

01 Claim Header – Sum of Line Item payments

02 Claim Detail – Individual Line Item payments

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 - 301

3. Value is not valid 102

CLAIMS FILES

Data Element Name: PLACE-OF-SERVICE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A code indicating where the service was performed. CMS 1500 values are used for this data element.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 11

Coding Requirements: Required.

Code Definition

01 Pharmacy

00-02 Unassigned

03 School

04 Homeless Shelter

05 Indian Health Service Free Standing Facility

06 Indian Health Service Provider-based Facility

07 Tribal 638 Free-standing Facility

08 Tribal 638 Provider-based Facility

09 Prison-correctional facility

10 Unassigned

11 Office

12 Home

13 Assisted Living Facility

14 Group Home

15 Mobile Unit

16 Temporary lodging

17 Walk-in retail health clinic

18-19 Unassigned

20 Urgent Care Facility

21 Inpatient Hospital

22 Outpatient Hospital

23 Emergency Room – Hospital

24 Ambulatory Surgery Center

25 Birthing Center

26 Military Treatment Facility

27-30 Unassigned

31 Skilled Nursing Facility, (obsolete)

32 Nursing Facility

33 Custodial Care Facility

34 Hospice

35-40 Unassigned

41 Ambulance (Land)

42 Ambulance (Air or Water)

43-48 Unassigned

49 Independent Clinic

50 Federally Qualified Health Center

51 Inpatient Psychiatric Facility

Code Definition

52 Psychiatric Facility Partial Hospitalization

53 Community Mental Health Center

54 Intermediate Care Facility/Mentally Retarded

55 Residential Substance Abuse Treatment Facility

56 Psychiatric Residential Treatment Center

57 Non-Residential Substance Abuse Treatment Facility

58-59 Unassigned

60 Mass Immunization Center

61 Comprehensive Inpatient Rehabilitation Facility

62 Comprehensive Outpatient Rehabilitation Facility

63-64 Unassigned

65 End Stage Renal Disease Treatment Facility

66-70 Unassigned

71 State or Local Public Health Clinic

72 Rural Health Clinic

73-80 Unassigned

81 Independent Laboratory

82-98 Unassigned

99 Other Unlisted Facility

Note: Value = 99 will be counted as error.

If there are new valid CMS 1500 PLACE- OF- SERVICE codes that are not listed in this dictionary, these codes may be used and will not trigger an error.

If TYPE-OF-SERVICE = {20, 21, 22} (capitated payment), fill with 88.

Error Condition

Resulting Error Code

1. Value is Non-Numeric - 812

2. Value = 99 301

3. Value Not one of the listed valid codes (including unassigned 203

Values = {00-02, 09-10, 16-19, 27-30, 35-40, 43-48, 58-59, 63-64,

66-70, 73-80, 82-87, 89-98})

4 Value = 88 AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> 88 AND TYPE-OF-SERVICE = {20, 21, 22, 23} 306

CLAIMS FILES

Data Element Name: PLAN-ID-NUMBER

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX- A unique number which represents the health plan under which the non-fee-for-service encounter was provided.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “53289”

Coding Requirements: Required.

Use the number as it is carried in the State’s system. I possible, this number should match the Plan ID number used on the eligible file. (TYPE-OF-CLAIM=3 OR TYPE-OF-SERVICE=20, 21, 22, 23)

If TYPE-OF-CLAIM<>3 (Encounter Record) AND TYPE-OF-SERVICE<>{20,21,22,23) 8-fill

If Value is unknown, could be 9-filled.

Error Condition Resulting Error Code

1. Value is “Space Filled” 303

2. Value = all 9's 301

3. Value = all 0's 304

4. Value = all 8's AND TYPE-OF-CLAIM = 3 509

5. Value = all 8’s AND TYPE OF SERVICE = {20, 21,22,23 )…………………………….……………....521

CLAIMS FILES

Data Element Name: PRE-AUTHORIZATION-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also called Prior Authorization or Referral Number).

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(18) 01CA79300

Coding Requirements: Required.

If Value is unknown, fill with "9999999999999999999999".

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999999999999 - 301

CLAIMS FILES

Data Element Name: PRESCRIBING-PROV-NPI-NUM

Definition: CLAIMRX – The National Provider ID (NPI) of the doctor responsible for prescribing a medication to a patient.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(10) “1234567890”

Coding Requirements: Required.

Record the value exactly as it appears in the State system. Do not 9-fill.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22)

If Value is unknown, fill with "9999999999".

Error Condition Resulting Error Code

1. Value = "9999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “8888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “8888888888" AND TYPE-OF-SERVICE = {20, 21, 22} 306

CLAIMS FILES

Data Element Name: PRESCRIBING-PROV-NUM

Definition: CLAIMRX - A unique identification number assigned to a provider which identifies the physician or other provider prescribing the drug, device or supply. For physicians, this must be the individual’s ID number, not a group identification number.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required/

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

If Value is unknown, fill with "999999999999".

If the prescribing physician provider ID is not available, but the physician’s Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value = PROVIDER-IDENTIFICATION-BILLING 524

CLAIMS FILES

Data Element Name: PRESCRIBING-PROV-SPECIALTY

Definition: CLAIMRX – This code indicates the area of specialty for the PRESCRIBING PROVIDER.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “01”

Coding Requirements: Required.

http://www.cms.hhs.gov/medicareprovidersupenroll/downloads/taxonomy.pdf

http://www.cms.hhs.gov/Transmittals/downloads/R1715CP.pdf

Valid Values Code Definition

01 General Practice

02 General Surgery

03 Allergy/Immunology

04 Otolaryngology

05 Anesthesiology

06 Cardiology

07 Dermatology

08 Family Practice

09 Interventional Pain Management

10 Gastroenterology

11 Internal Medicine

12 Osteopathic Manipulative Therapy

13 Neurology

14 Neurosurgery

16 Obstetrics/Gynecology

17 Hospice and Palliative Care

18 Ophthalmology

19 Oral Surgery (dentists only)

20 Orthopedic Surgery

21 Available

22 Pathology

23 Available

24 Plastic and Reconstructive Surgery

25 Physical Medicine and Rehabilitation

26 Psychiatry

27 Available

28 Colorectal Surgery (formerly proctology)

29 Pulmonary Disease

30 Diagnostic Radiology

CLAIMS FILES

31 Available

32 Anesthesiologist Assistants

33 Thoracic Surgery

34 Urology

35 Chiropractic

36 Nuclear Medicine

37 Pediatric Medicine

38 Geriatric Medicine

39 Nephrology

40 Hand Surgery

41 Optometry

44 Infectious Disease

46 Endocrinology

48 Podiatry

66 Rheumatology

70 Single or Multispecialty Clinic or Group Practice

72 Pain Management

73 Mass Immunization Roster Biller

74 Radiation Therapy Center

75 Slide Preparation Facilities

76 Peripheral Vascular Disease

77 Vascular Surgery

78 Cardiac Surgery

79 Addiction Medicine

81 Critical Care (Intensivists)

82 Hematology

83 Hematology/Oncology

84 Preventive Medicine

85 Maxillofacial Surgery

86 Neuropsychiatry

90 Medical Oncology

91 Surgical Oncology

92 Radiation Oncology

93 Emergency Medicine

94 Interventional Radiology

98 Gynecological/Oncology

99 Unknown Physician Specialty

A0 Hospital

A1 Skilled Nursing Facility

A2 Intermediate Care Nursing Facility

A3 Other Nursing Facility

A4 Home Health Agency

A5 Pharmacy

A6 Medical Supply Company with Respiratory Therapist

A7 Department Store

A8 Grocery Store

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: PRESCRIBING-PROV-TAXONOMY

Definition: CLAIMRX

For CLAIMRX files, the taxonomy code for the medical provider writing the prescription.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22)

If Value is unknown, fill with "999999999999".

Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.

http://www.wpc-edi.com/content/view/793/1

Error Condition Resulting Error Code

3. Value is 0-filled 304

4. Value = “888888888888" AND TYPE-OF-SERVICE <> {20, 21, 22,23} 305

5. Value <> “888888888888" AND TYPE-OF-SERVICE = {20, 21, 22,23} 306

CLAIMS FILES

Data Element Name: PRESCRIBING-PROV-TYPE

Definition: CLAIMRX - A code describing the type of entity prescribing the drug, device or supply.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 01

Coding Requirements: Required

Valid Values Code Definition

01 General Hospital

02 Special Hospital/Outpatient Rehabilitation Facility

03 Psychiatric Hospital

05 Community Mental Health Center

19 End Stage Renal Hospital

20 Pharmacy

25 Physician (MD)

26 Physician (DO)

27 Podiatrist

28 Chiropractor

29 Physician Assistant

30 Advanced Registered Nurse Practitioner (ARNP)

31 CRNA

32 Psychologist

34 Licensed Midwife

35 Dentist

36 Registered Nurse (RN)

37 Licensed Practical Nurse (LPN)

38 Nursing Attendant

39 Massage Therapist

40 Ambulance

41 Contract Nurse

42 Air/Water Ambulance Company

43 Taxi

44 Public Transportation

45 Private Transportation

46 Hospice

50 Independent Laboratory

51 Portable X-Ray Company

52 Alternative Medicine

53 Non-Medical Vendor

54 Prosthetics/Orthotics

55 Vocational Rehabilitation (Training, Tuition and Schools)

56 Vocational Rehabilitation Counselor

57 Rehabilitation Maintenance

58 Assisted Re-employment

59 Relocation Expenses

60 Audiologist/Speech Pathologist

61 Second Opinion Contractor

62 Optometrist

63 Optician

65 Home Health Agency

66 Rural Health Clinic

68 Federally Qualified Health Center

69 Birthing Center

70 HMO or PHP

71 Physical Therapist

72 Occupational Therapist

73 Pulmonary Rehabilitation

74 Outpatient Renal Dialysis Facility

75 Medical Supplies/Durable Medical Equipment (DME)

76 Case Management Agency

77 Social Worker

78 Blood Bank

79 Alternative Payee

80 Pay-to-Intermediary

88 Ambulatory Surgery Center

89 Federal Facility (VA Hospital)

90 Skilled Nursing Facility (SNF)-Medicare Certified

91 Skilled Nursing Facility (SNF)-Non-Medicare Certified

92 Intermediate Care Facility (ICF)

93 Rural Hospital Swing Bed

94 Boarding House

95 Insurance Company (Third Party Carriers)

96 Other Provider

97 Billing Agent

98 Lien holder

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: PRESCRIPTION-FILL-DATE

Definition: CLAIMRX- Date the drug, device or supply was dispensed by the provider

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

If date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

4. Value > END-OF-TIME-PERIOD in the Header Record 506

CLAIMS FILES

Data Element Name: PRESCRIPTION-NUM

Definition: CLAIMRX- The unique identification number assigned by the pharmacy or supplier to the prescription.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(07) “R12345X”

Coding Requirements: Required.

If not known, fill with 9999999

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999 - 301

CLAIMS FILES

Data Element Name: PROCEDURE-CODE (1)

Definition: CLAIMIP, CLAIMOT,CLAIMLT - A code used by the State to identify the principal procedure performed during the hospital stay referenced by this claim. A principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(08) “123456 “

Coding Requirements: Required.

If no principal procedure was performed, fill with "88888888".

ICD-9/10-CM codes are the HIPAA standard for procedure codes on inpatient claims. When ICD-9/10-CM coding is used, the PROC-CD-FLAG-1=02/07) and Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-7 must be blank.

Value must be a valid code. If PROC-CD-FLAG-1 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats:

CPT (PROC-CD-FLAG-1=01): Positions 1-5 should be numeric and position 6-7 must be blank.

HCPCS (PROC-CD-FLAG-1=06): Position 1 must be an alpha character (“A”-“Z”) and position 6-7 must be blank.. Value can include both National and Local ( Regional) codes. For National codes (position 1=“A”-“V” ) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234").

If value is unknown, fill with "99999999".

Note: An eighth character is provided for future expansion of this field.

CLAIMS FILES

Data Element Name: PROCEDURE-CODE (1) (continued)

Error Condition Resulting Error Code

1. Value = "99999999" 301

2. Value = “00000000" 304

3. Value is “Space Filled” 303

4. Value <> "88888888" AND PROC-CODE-FLAG-1 = 88 306

5. Value = "88888888" AND PROC-CODE-FLAG-1<> 88 305

6. Value is invalid as related to PROC-CODE-FLAG-1=01 (CPT-4) 203

7. Value is invalid as related to PROC-CODE-FLAG-1=02/07 (ICD-9/10) 203

8. Value is invalid as related to PROC-CODE-FLAG-1=06 (HCPCS) 203

CLAIMS FILES

Data Element Name: PROCEDURE-CODE (2) THRU PROCEDURE-CODE (6)

Definition: CLAIMIP - A series of up to five codes used by the State to identify the procedures performed in addition to the principal procedure. during the hospital stay referenced by this claim.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(08) “123456 “

Coding Requirements: Conditional.

Enter as many procedures as are reported after the principal procedure up to five additional codes. Remaining fields should be 8-filled (e.g., if claim contains two additional procedures, they would be reported in PROC-CODE-2 and

PROC-CODE-3. Remaining fields PROC-CODE-4 through PROC-CODE-6 would all be 8-filled.)

ICD-9/10-CM codes are the HIPAA standard for procedure codes on inpatient claims. When ICD-9/10-CM coding is used, the PROC-CODE-FLAG-1=02) and Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-7 must be blank.

Value must be a valid code. If PROC-CODE-FLAG-1 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State.

For national coding systems, code should conform to the nationally recognized formats:

CPT (corresponding PROC-CODE-FLAG = 01): Positions 1-5 should be numeric and position 6-8 must be blank.

ICD-9/10-CM (corresponding PROC-CODE-FLAG = 02/07): Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-8 must be blank.

HCPCS (corresponding PROC-CODE-FLAG = 06): Position 1 must be an alpha character (“A”-“Z”) and position 6-7 must be blank.. Value can include both National and Local (Regional) codes. For National codes (position 1=“A”-“V” ) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234").

For other schemes which are not nationally recognized, states should supply CMS with lists of valid values and any formats which should apply.

If value is unknown, fill with “99999999".

Note: An eighth character is provided for future expansion of this field.

CLAIMS FILES

Data Element Name: PROCEDURE-CODE (2) thru PROCEDURE-CODE (6) (continued)

Error Condition Resulting Error Code

1. Value is = "99999999" 301

2. Value = “00000000" 304

3. Value is “Space Filled” 303

4. Value is <> "88888888" 306

AND corresponding PROC-CODE-FLAG = 88

5. Value is = "88888888" 305

AND corresponding PROC-CODE-FLAG <> 88

6. Value is invalid as related to corresponding PROC-CODE-FLAG= 01 (CPT-4) 203

7. Value is invalid as related to corresponding PROC-CODE-FLAG = 02 (ICD-9/10-CM). 203

8. Value is invalid as related to corresponding PROC-CODE-FLAG = 06 (HCPCS) 203

CLAIMS FILES

Data Element Name: PROCEDURE-CODE-FLAG (1)

Definition: CLAIMIP,CLAIMLT, CLAIMOT - A flag that identifies the coding system used for the PROC-CODE-1.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(02) 01

Coding Requirements: Required.

Valid Values Code Definition

01 CPT‑4

02 ICD-9‑CM

03 CRVS 74 (Obsolete)

04 CRVS 69 (Obsolete)

05 CRVS 64 (Obsolete)

06 HCPCS (Both National and Regional HCPCS)

07 ICD-10-CM

10 ‑ 87 Other Systems

88 Not Applicable

99 Unknown

If no principal procedure was performed, fill with 88.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 812

2. Value = 99 301

3. Value is not in the list of valid codes, above 201

4. Value <> 88 AND MEDICAID-COVERED-INPATIENT-DAYS= +00000 520

5. Value = 07 AND Coding Scheme has not yet been implemented 511

(BEGINNING-DATE-OF-SERVICE < implementation date: current

estimate = year 2013)

CLAIMS FILES

Data Element Name: PROCEDURE-CODE-FLAG (2) THRU PROCEDURE-CODE-FLAG (6)

Definition: CLAIMIP - A series of flags that identifies the coding system used for the associated procedure codes (PROC-CODE-2 through PROC-CODE-6)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(2) 01

Coding Requirements: Conditional.

Valid Values Code Definition

01 CPT‑4

02 ICD-9/10‑CM

03 CRVS 74 (Obsolete)

04 CRVS 69 (Obsolete)

05 CRVS 64 (Obsolete)

06 HCPCS (Both National and Regional HCPCS)

07 ICD-9/10 CM (Not yet been implemented. For future use)

10 ‑ 87 Other Systems

88 Not Applicable

99 Unknown

If no Second Procedure was performed, fill with 88.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 812

2. Value is = 99 301

3. Value is not in the list of valid codes, above 201

4. Value <> 88 AND MEDICAID-COVERED-DAYS = +00000 520

5. Value in PROC-CODE-FLAG-2 through 6 <> 88 AND PROC-CODE-FLAG-1 = “88" 306

6. Array range should not contain imbedded 88 coded fields (e.g., one

field has value 88, all remaining fields should also contain = 88). 306

7. Value= 07 AND Coding Scheme has not yet been implemented 511

(BEGINNING-DATE-OF-SERVICE < implementation date: current

estimate = year 2013)

CLAIMS FILES

Data Element Name: PROCEDURE-CODE-MOD (1)

Definition: CLAIMIP, CLAIMOT CLAIMLT - The procedure code modifier used with the (Principal) Procedure Code 1. For example, some States use modifiers to indicate assistance in surgery or anesthesia services.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(2) " "

Coding Requirements: Required.

A list of valid codes must be supplied by the State prior to submission of any file data.

If no Principal Procedure was performed, fill with "88".

If a modifier is not applicable, fill with " ".

Error Condition Resulting Error Code

1. Value = “88" AND PROC-CODE-1 <> “88888888" 305

2. Value <> “88" AND PROC-CODE-1 = “88888888" 306

CLAIMS FILES

Data Element Name: PROCEDURE-CODE-MOD (2) THRU PROCEDURE-CODE-MOD (6)

Definition: CLAIMIP - A series of procedure code modifiers used with the corresponding Procedure Codes. For example, some States use modifiers to indicate assistance in surgery or anesthesia services.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(2) " "

Coding Requirements: Conditional.

A list of valid codes must be supplied by the State prior to submission of any file data.

If no corresponding procedure (PROC-CODE-2 through PROC-CODE-6) was performed, fill modifier with "88".

If a modifier is not applicable, fill with " ".

Error Condition Resulting Error Code

1. Value = “88" AND corresponding PROC-CODE <> “88888888" 305

2. Value <> “88" AND corresponding PROC-CODE = “88888888" 306

CLAIMS FILES

Data Element Name: PROCEDURE-CODE- DATE(1)

Definition: CLAIMIP, CLAIMLT, CLAIMOT - The date on which the principal procedure was performed.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements:

Value must be a valid date in CCYYMMDD format.

If date is not known, fill with 99999999

If PROC-CODE-1 = “88888888", fill with 88888888

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value <> 88888888 AND PROC-CODE-1 = "88888888" 306

4. Value = 88888888 AND PROC-CODE-1 <> "88888888" 305

5. Value is not a valid date 102

6. Value < BEGINNING-DATE-OF-SERVICE. 511

7. Value > ENDING-DATE-OF-SERVICE. 517

CLAIMS FILES

Data Element Name: PROCEDURE-CODE- DATE (2) - PROCEDURE-CODE- DATE(6)

Definition: CLAIMIP - The date on which the procedure 2 – 6 was performed.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required.

Value must be a valid date in CCYYMMDD format.

If PROC-CODE-2 - 6 = “88888888", fill with 88888888

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value <> 88888888 AND PROC-CODE-1 = "88888888" 306

4. Value = 88888888 AND PROC-CODE-1 <> "88888888" 305

5. Value is not a valid date 102

6. Value < BEGINNING-DATE-OF-SERVICE. 511

7. Value > ENDING-DATE-OF-SERVICE. 517

CLAIMS FILES

Data Element Name: PROCEDURE-DATE

Definition: CLAIMLT, CLAIMOT. The date upon which the procedure was performed.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required.

Value must be a valid date in CCYYMMDD format.

If date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date 102

4. Value < BEGINNING-DATE-OF-SERVICE. 511

5. Value > ENDING-DATE-OF-SERVICE. 517

CLAIMS FILES

Data Element Name: PROGRAM-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX- Code indicating special Medicaid program under which the service was provided. Refer to Attachment 5 for information on the various program types. The valid values are arranged in hierarchical order from highest priority to lowest. The hierarchy should be used to when a claim falls into multiple types. The hierarchy of existing program types (00-07) is based on a State Medicaid Directors' letter dated November 24, 1998.

Field Description:

COBOL Example

PICTURE Value

X(02) “05”

Valid Values Code Definition

0C State Plan CHIP

0A Money Follows Patient (MFP) service package

02 Family Planning

06 Home and Community Based Care (HCBC) for Disabled Elderly and Individuals Age 65 and Older

07 Home and Community Based Care (HCBC) Waiver Services

01 EPSDT

05 Indian Health Services

03 Rural Health Clinic (RHC)

04 Federally Qualified Health Centers (FQHC)

08 Psychiatric Rehab facility for children

00 No Special Program

99 Unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value is 99 301

CLAIMS FILES

Data Element Name: PROVIDER-LOCATION-CODE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – This is a code that uniquely identifies the geographic location of a provider where the provider’s service has been given; this code is applicable if the provider is a chain, operating in more than one geographic location. This code may be used in conjunction with the billing provider number.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “27”

Coding Requirements: Required

The value should correspond with one of the location identifiers recorded in the provider’s demographic records in the TMSIS data set.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: QUANTITY-ACTUAL

Definition: , CLAIMOT, CLAIMRX – The quantity of a drug or a service that is dispensed per prescription per date of service or per month.

QUANTITY-ACTUAL: CLAIMRX

QUANTITY-ACTUAL-1 through QUANTITY-ACTUAL-5: CLAIMOT

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(03)V99 013455

Coding Requirements: Required

This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder‑filled vials, use 1 as the number of units.

NOTE==> One prescription for 100 250‑milligram tablets results in QUANTITY‑OF‑SERVICE=100.

This field is not applicable for institutional services, dental services, laboratory and x-ray services, premium payments, or miscellaneous services (includes claims with TYPES-OF-SERVICE 09, 15, 17, 19, 20, 21, 22,23). Fill with +00000 for these types of services.

If invalid or missing, fill with +00000.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = -88888

2. Value = +99999 - 301

3. Value <> +88888 AND TYPE-OF-SERVICE = {09, 15, 306

19, 20, 21, 22,23}

4. Value = +88888 AND (TYPE-OF-SERVICE = {08, 305

10 through 14, 16, or 18} AND TYPE-OF-CLAIM = {1 or 2})

5. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

6. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: QUANTITY-ALLOWED

Definition: CLAIMOT, CLAIMRX – The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed.

QUANTITY-ALLOWED: CLAIMRX

QUANTITY-ALLOWED-1 through QUANTITY-ALLOWED-5: CLAIMOT

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(03)V99 12345

Coding Requirements: Required.

NOTE==> One prescription for 100 250‑milligram tablets results in QUANTITY‑ALLOWED=100.

If invalid or missing, fill with +00000.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = -88888

2. Value = +99999 - 301

3. Value <> +88888 AND TYPE-OF-SERVICE = {09, 15, 306

19, 20, 21, 22,23}

4. Value = +88888 AND (TYPE-OF-SERVICE = {08, 305

10 through 14, 16, or 18} AND TYPE-OF-CLAIM = {1 or 2})

5. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

7. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: QUANTITY-OF-SERVICE

Definition: On facility claim entries, this field is to capture service quantify by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed.

On professional claim entries, use this field to capture visits, treatments, procedures, tests, units of supplies, anesthesia minutes, oxygen volume, etc. If only one service is performed, the numeral 1 must be entered.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(03)V99 02345

Coding Requirements: Required.

This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled,

This field is not applicable for institutional services, dental services, laboratory and x-ray services, premium payments, or miscellaneous services (includes claims with TYPES-OF-SERVICE 09, 15, 19, 20, 21, 22,23) If invalid or missing, fill with +00000.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = -88888

2. Value = +99999 301

3. Value <> +00000 AND TYPE-OF-SERVICE = {09, 15, 306

19, 20, 21, 22}

4. Value = +00000 AND (TYPE-OF-SERVICE = {08, 305

10 through 14, 16, or 18} AND TYPE-OF-CLAIM = {1 or 2})

5. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

6. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: REBATE-ELIGIBLE-INDICATOR

Definition: CLAIMRX - An indicator to identify claim lines with an NDC that is eligible for the drug rebate program.

Field Description:

COBOL Example

PICTURE Value

9(01) 1

Coding Requirements: Required.

Valid Values Code Definition

0 NDC is not eligible for drug rebate program

1 NDC is eligible for drug rebate program

9 The drug rebate eligibility of the is unknown

Error Condition Resulting Error Code

1. Value = "9" 301

2. Value is not in the valid values list ???

CLAIMS FILES

Data Element Name: REBATE-UNITS-REIMBURSED

Definition: CLAIMRX - The number of FFS or MCO units of the drug reimbursed by the state.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If the field is not applicable, enter all 8s..

If the field is applicable, but the amount is unknown, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = "99999999999" 301

CLAIMS FILES

Data Element Name: RECORD-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The code used to denote if the record is a header or a detail.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) “01”

Coding Requirements:

Valid Values Code Definition

0 File Header

1 Claim Header

2 Claim Detail

Error Condition Resulting Error Code

1. Value = "9" 301

2. Value is “Space Filled” 303

CLAIMS FILES

Data Element Name: REFERRING-PROV-NPI-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT – The National Provider ID (NPI) of the referring entity responsible for billing a patient for healthcare services.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(10) “1234567890”

Coding Requirements: Required.

Record the value exactly as it appears in the State system. Do not 9-fill.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22,23)

If Value is unknown, fill with "9999999999".

Error Condition Resulting Error Code

1. Value = "9999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “8888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “8888888888" AND TYPE-OF-SERVICE = {20, 21, 22,23} 306

CLAIMS FILES

Data Element Name: REFERRING-PROV-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT - A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual’s ID number, not a group identification number.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required.

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

If Value is unknown, fill with "999999999999".

If the prescribing physician provider ID is not available, but the physician’s Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element.

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value = PROVIDER-IDENTIFICATION-BILLING 524

CLAIMS FILES

Data Element Name: REFERRING-PROV-SPECIALTY

Definition: CLAIMIP, CLAIMLT,CLAIMOT – This code indicates the area of specialty of the REFERRING PROVIDER.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “09”

Coding Requirements: Required.

http://www.cms.hhs.gov/medicareprovidersupenroll/downloads/taxonomy.pdf

http://www.cms.hhs.gov/Transmittals/downloads/R1715CP.pdf

Valid Values Code Definition

01 General Practice

02 General Surgery

03 Allergy/Immunology

04 Otolaryngology

05 Anesthesiology

06 Cardiology

07 Dermatology

08 Family Practice

09 Interventional Pain Management

10 Gastroenterology

11 Internal Medicine

12 Osteopathic Manipulative Therapy

13 Neurology

14 Neurosurgery

16 Obstetrics/Gynecology

17 Hospice and Palliative Care

18 Ophthalmology

19 Oral Surgery (dentists only)

20 Orthopedic Surgery

21 Available

22 Pathology

23 Available

24 Plastic and Reconstructive Surgery

25 Physical Medicine and Rehabilitation

26 Psychiatry

27 Available

28 Colorectal Surgery (formerly proctology)

29 Pulmonary Disease

30 Diagnostic Radiology

CLAIMS FILES

31 Available

32 Anesthesiologist Assistants

33 Thoracic Surgery

34 Urology

35 Chiropractic

36 Nuclear Medicine

37 Pediatric Medicine

38 Geriatric Medicine

39 Nephrology

40 Hand Surgery

41 Optometry

44 Infectious Disease

46 Endocrinology

48 Podiatry

66 Rheumatology

70 Single or Multispecialty Clinic or Group Practice

72 Pain Management

73 Mass Immunization Roster Biller

74 Radiation Therapy Center

75 Slide Preparation Facilities

76 Peripheral Vascular Disease

77 Vascular Surgery

78 Cardiac Surgery

79 Addiction Medicine

81 Critical Care (Intensivists)

82 Hematology

83 Hematology/Oncology

84 Preventive Medicine

85 Maxillofacial Surgery

86 Neuropsychiatry

90 Medical Oncology

91 Surgical Oncology

92 Radiation Oncology

93 Emergency Medicine

94 Interventional Radiology

98 Gynecological/Oncology

99 Unknown Physician Specialty

A0 Hospital

A1 Skilled Nursing Facility

A2 Intermediate Care Nursing Facility

A3 Other Nursing Facility

A4 Home Health Agency

A5 Pharmacy

A6 Medical Supply Company with Respiratory Therapist

A7 Department Store

A8 Grocery Store

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: REFERRING-PROV-TAXONOMY

Definition: CLAIMIP, CLAIMLT, CLAIMOT

For CLAIMOT files, the taxonomy code for the provider who referred the beneficiary for treatment (as opposed to the provider “billing” for the service).

For CLAIMIP and CLAIMLT files the taxonomy code for the institution billing/caring for the beneficiary.

For CLAIMRX files, the taxonomy code for the billing provider.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22)

If Value is unknown, fill with "999999999999".

Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.

http://www.wpc-edi.com/content/view/793/1

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “888888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “888888888888" AND TYPE-OF-SERVICE = {20, 21, 22} 306

CLAIMS FILES

Data Element Name: REFERRING-PROV-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT- A code describing the type of provider (i.e. doctor) responsible for referring a patient’s

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 01

Coding Requirements: Required

Valid Values Code Definition

01 General Hospital

02 Special Hospital/Outpatient Rehabilitation Facility

03 Psychiatric Hospital

05 Community Mental Health Center

19 End Stage Renal Hospital

20 Pharmacy

25 Physician (MD)

26 Physician (DO)

27 Podiatrist

28 Chiropractor

29 Physician Assistant

30 Advanced Registered Nurse Practitioner (ARNP)

31 CRNA

32 Psychologist

34 Licensed Midwife

35 Dentist

36 Registered Nurse (RN)

37 Licensed Practical Nurse (LPN)

38 Nursing Attendant

39 Massage Therapist

40 Ambulance

41 Contract Nurse

42 Air/Water Ambulance Company

43 Taxi

44 Public Transportation

45 Private Transportation

46 Hospice

50 Independent Laboratory

51 Portable X-Ray Company

52 Alternative Medicine

53 Non-Medical Vendor

54 Prosthetics/Orthotics

55 Vocational Rehabilitation (Training, Tuition and Schools)

56 Vocational Rehabilitation Counselor

57 Rehabilitation Maintenance

58 Assisted Re-employment

59 Relocation Expenses

60 Audiologist/Speech Pathologist

61 Second Opinion Contractor

62 Optometrist

63 Optician

65 Home Health Agency

66 Rural Health Clinic

68 Federally Qualified Health Center

69 Birthing Center

70 HMO or PHP

71 Physical Therapist

72 Occupational Therapist

73 Pulmonary Rehabilitation

74 Outpatient Renal Dialysis Facility

75 Medical Supplies/Durable Medical Equipment (DME)

76 Case Management Agency

77 Social Worker

78 Blood Bank

79 Alternative Payee

80 Pay-to-Intermediary

88 Ambulatory Surgery Center

89 Federal Facility (VA Hospital)

90 Skilled Nursing Facility (SNF)-Medicare Certified

91 Skilled Nursing Facility (SNF)-Non-Medicare Certified

92 Intermediate Care Facility (ICF)

93 Rural Hospital Swing Bed

94 Boarding House

95 Insurance Company (Third Party Carriers)

96 Other Provider

97 Billing Agent

98 Lien holder

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: REMITTANCE-DATE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The Remittance Payment Date or the Date of the remittance cycle.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(08) 20090531

Coding Requirements: Required.

Value must be a valid date in CCYYMMDD format.

If date is not known, fill with 99999999

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

CLAIMS FILES

Data Element Name: REMITTANCE-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date YYDDD format.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(10) 092976786

Error Condition Resulting Error Code

1. Value = "99999999999999999999" 301

2. Value = “00000000000000000000" 304

3. Value is “Space Filled” 303

4. Value <> "88888888888888888888" AND SERVICE-CODE-FLAG = 88 306

CLAIMS FILES

Data Element Name: SELF-DIRECTION TYPE

Definition: A data element to identify how the beneficiary self-directed the service. Hiring Authority (the beneficiary has decision-making authority to recruit, hire, train and supervise the individuals who furnish his/her services.) Budget Authority (The beneficiary has decision-making authority over how the Medicaid funds in a budget are spent.) both Hiring and Budget Authority.

Field Description:

COBOL Example

PICTURE Value

9(03) “001”

Coding Requirements: Required.

Valid Values Code Definition

000 Not Applicable

001 Hiring Authority

002 Budget Authority

003 Hiring and Budget Authority

999 Type of Authority Is Unknown

Error Condition Resulting Error Code

1. Value = "999" 301

2. Value is not in the valid values list 303

CLAIMS FILES

Data Element Name: SERVICE-SUBCATEGORY (Future)

Definition: CLAIMIP, CLAIMLT, CLAIMOT – Subcategory of TYPE-OF-SERVICE; provides additional detail on the service provided.

For Inpatient Services, Subcategories include: Medical surgery, ICU, Psych Tiers; Maternity, Nursery, and NICU; Hospice; SNF; and other services.

For Outpatient Services, Subcategories include: Dialysis; ER; Clinic Services; Surgery; Lab and Radiology; and all other services.

For Other (Physician and Professional Services), Subcategories include: Well Child/Preventable; Adult Preventable; Obstetrical Care; Dialysis; Vision; Hearing; Lab and Radiology; Therapy; Drugs; Physician Services (Inpatient); Physician Services (Outpatient); Physician Services (Office); Physician Services (Urgent).

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 09

Coding Requirements: Required. FUTURE

Valid values to be provided. FUTURE

Error Condition Resulting Error Code

Error conditions to be determined.

CLAIMS FILES

Data Element Name: SERVICING-PROV-NPI-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT – The National Provider ID (NPI) of the rendering/attending provider responsible for the beneficiary

For CLAIMOT files the unique number to identify the provider who treated the recipient (as opposed to the provider “billing” for the service).

For CLAIMRX files, the unique number identifying the provider which filled the prescription..

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(10) Record the value exactly as it appears in the State system. Do not 9-fill.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22)

If Value is unknown, fill with "9999999999".

Error Condition Resulting Error Code

1. Value = "9999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “8888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “8888888888" AND TYPE-OF-SERVICE = {20, 21, 22,23} 306

CLAIMS FILES

Data Element Name: SERVICING-PROV-NUM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, - A unique number to identify the provider who treated the recipient (as opposed to the provider “billing” for the service, see PROVIDER-ID-NUMBER-BILLING)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Valid formats must be supplied by the State in advance of submitting file data.

If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.

If “Servicing” provider and the “Billing” provider are the same then use the same number in both fields.

For institutional billing providers (TYPE-OF-SERVICE = 11, 12) and other providers operating as a group,

the numbers should be different.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22,23)

If Value is unknown, fill with "999999999999".

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “888888888888" AND TYPE-OF-SERVICE <> {20, 21, 22, 23} 305

5. Value <> “888888888888" AND TYPE-OF-SERVICE = {20, 21, 22,23} 306

CLAIMS FILES

Data Element Name: SERVICING-PROV-SPECIALTY

Definition: CLAIMIP, CLAIMOT, CLAIMLT – This code indicates the area of specialty for the SERVICING PROVIDER.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “01”

Coding Requirements: Required.

http://www.cms.hhs.gov/medicareprovidersupenroll/downloads/taxonomy.pdf

http://www.cms.hhs.gov/Transmittals/downloads/R1715CP.pdf

Valid Values Code Definition

01 General Practice

02 General Surgery

03 Allergy/Immunology

04 Otolaryngology

05 Anesthesiology

06 Cardiology

07 Dermatology

08 Family Practice

09 Interventional Pain Management

10 Gastroenterology

11 Internal Medicine

12 Osteopathic Manipulative Therapy

13 Neurology

14 Neurosurgery

16 Obstetrics/Gynecology

17 Hospice and Palliative Care

18 Ophthalmology

19 Oral Surgery (dentists only)

20 Orthopedic Surgery

21 Available

22 Pathology

23 Available

24 Plastic and Reconstructive Surgery

25 Physical Medicine and Rehabilitation

26 Psychiatry

27 Available

28 Colorectal Surgery (formerly proctology)

29 Pulmonary Disease

30 Diagnostic Radiology

CLAIMS FILES

31 Available

32 Anesthesiologist Assistants

33 Thoracic Surgery

34 Urology

35 Chiropractic

36 Nuclear Medicine

37 Pediatric Medicine

38 Geriatric Medicine

39 Nephrology

40 Hand Surgery

41 Optometry

44 Infectious Disease

46 Endocrinology

48 Podiatry

66 Rheumatology

70 Single or Multispecialty Clinic or Group Practice

72 Pain Management

73 Mass Immunization Roster Biller

74 Radiation Therapy Center

75 Slide Preparation Facilities

76 Peripheral Vascular Disease

77 Vascular Surgery

78 Cardiac Surgery

79 Addiction Medicine

81 Critical Care (Intensivists)

82 Hematology

83 Hematology/Oncology

84 Preventive Medicine

85 Maxillofacial Surgery

86 Neuropsychiatry

90 Medical Oncology

91 Surgical Oncology

92 Radiation Oncology

93 Emergency Medicine

94 Interventional Radiology

98 Gynecological/Oncology

99 Unknown Physician Specialty

A0 Hospital

A1 Skilled Nursing Facility

A2 Intermediate Care Nursing Facility

A3 Other Nursing Facility

A4 Home Health Agency

A5 Pharmacy

A6 Medical Supply Company with Respiratory Therapist

A7 Department Store

A8 Grocery Store

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: SERVICING-PROV-TAXONOMY

Definition: CLAIMIP, CLAIMLT, CLAIMOT,

For CLAIMOT files, the taxonomy code for the provider who treated the recipient (as opposed to the provider “billing” for the service).

For CLAIMIP and CLAIMLT files the taxonomy code for the institution billing/caring for the beneficiary.

For CLAIMRX files, the taxonomy code for the billing provider.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “01CA79300000”

Coding Requirements: Required.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22,23)

If Value is unknown, fill with "999999999999".

Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.

http://www.wpc-edi.com/content/view/793/1

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

4. Value = “888888888888" AND TYPE-OF-SERVICE <> {20, 21, 22,23} 305

5. Value <> “888888888888" AND TYPE-OF-SERVICE = {20, 21, 22,23} 306

CLAIMS FILES

Data Element Name: SERVICING-PROV-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, - A code describing the type of provider (i.e. doctor or facility) responsible for treating a patient.

For CLAIMOT files, it is the type of provider who treated the patient (opposed to the provider or entity “billing” for the service)

For CLAIMIP or CLAIMLT, this represents the attending physician if available.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 01

Coding Requirements: Required

Valid Values Code Definition

01 General Hospital

02 Special Hospital/Outpatient Rehabilitation Facility

03 Psychiatric Hospital

05 Community Mental Health Center

19 End Stage Renal Hospital

20 Pharmacy

25 Physician (MD)

26 Physician (DO)

27 Podiatrist

28 Chiropractor

29 Physician Assistant

30 Advanced Registered Nurse Practitioner (ARNP)

31 CRNA

32 Psychologist

34 Licensed Midwife

35 Dentist

36 Registered Nurse (RN)

37 Licensed Practical Nurse (LPN)

38 Nursing Attendant

39 Massage Therapist

40 Ambulance

41 Contract Nurse

42 Air/Water Ambulance Company

43 Taxi

44 Public Transportation

45 Private Transportation

46 Hospice

50 Independent Laboratory

51 Portable X-Ray Company

52 Alternative Medicine

53 Non-Medical Vendor

54 Prosthetics/Orthotics

55 Vocational Rehabilitation (Training, Tuition and Schools)

56 Vocational Rehabilitation Counselor

57 Rehabilitation Maintenance

58 Assisted Re-employment

59 Relocation Expenses

60 Audiologist/Speech Pathologist

61 Second Opinion Contractor

62 Optometrist

63 Optician

65 Home Health Agency

66 Rural Health Clinic

68 Federally Qualified Health Center

69 Birthing Center

70 HMO or PHP

71 Physical Therapist

72 Occupational Therapist

73 Pulmonary Rehabilitation

74 Outpatient Renal Dialysis Facility

75 Medical Supplies/Durable Medical Equipment (DME)

76 Case Management Agency

77 Social Worker

78 Blood Bank

79 Alternative Payee

80 Pay-to-Intermediary

88 Ambulatory Surgery Center

89 Federal Facility (VA Hospital)

90 Skilled Nursing Facility (SNF)-Medicare Certified

91 Skilled Nursing Facility (SNF)-Non-Medicare Certified

92 Intermediate Care Facility (ICF)

93 Rural Hospital Swing Bed

94 Boarding House

95 Insurance Company (Third Party Carriers)

96 Other Provider

97 Billing Agent

98 Lien holder

Error Condition Resulting Error Code

1. Value = "99" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: SERVICE-TRACKING-TYPE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – This code indicates the type of service that is tracking the claim. This field is relevant only for TYPE OF CLAIM equaling 4.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 09

Coding Requirements: Required.

Valid Values Code Definition

00 Not a Service Tracking Claim

01 Drug Rebate

02 DSH Payment

03 Lump Sum Payment

04 Cost Settlement

05 Supplemental

06 Other

99 Unknown

Error Condition Resulting Error Code

Not a numeric value.

Value is not a valid value.
CLAIMS FILES

Data Element Name: SERVICE-TRACKING-PAYMENT-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – This field provides the paid amount for each SERVICE TRACKING claim.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

Error Condition Resulting Error Code

Coding Requirements: Required

If invalid or unknown, fill with +0.

Amount paid for services received by an individual patient, when the state accepts a lump sum form a provider that covered similar services delivered to more than one patient, such as a group screening for EPSDT. .

For service tracking payments, ensure that the MEDICIAD-PAYMENT-AMOUNT is 0 filled and provide payment amount in SERVICE-TRACKING-PAYMENT-AMT only..

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2 Value < +00000000 AND ADJUSTMENT-INDICATOR = {0, 2 or 4} 607

3 Value > +00000000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: SOURCE-LOCATION

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX

The field denotes the claims payment system from which the claim was extracted.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 01

Coding Requirements: Required.

Valid Values Code Definition

01 MMIS

02 Non-MMIS CHIP Payment System

03 Pharmacy Benefits Manager (PBM) Vendor

04 Dental Benefits Manager Vendor

05 Transportation Provider System

06 Mental Health Claims Payment System

07 Financial Transaction/Accounting System

08 Other State Agency Claims Payment System

09 County/Local Government Claims Payment System

10 Other Vendor/Other Claims Payment System 1

11 Other Vendor/Other Claims Payment System 2

12 Other Vendor/Other Claims Payment System 3

13 Other Vendor/Other Claims Payment System 4

14 Other Vendor/Other Claims Payment System 5

15 Other Vendor/Other Claims Payment System 6

16 Other Vendor/Other Claims Payment System 7

17 Other Vendor/Other Claims Payment System 8

18 Other Vendor/Other Claims Payment System 9

19 Other Vendor/Other Claims Payment System 10

20 Managed Care Organization (MCO)

Error Condition Resulting Error Code

Value is non-numeric.

Value is not a valid value.

CLAIMS FILES

Data Element Name: SPLIT-CLAIM-IND

Definition: CLAIMIP - An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(01) “U”

If the claim has been split, the Transaction Handling Code indicator will indicate a Split

Payment and Remittance (1000 BPR01 = U).

Error Condition Resulting Error Code

1. Value = "9" 301

2. Value = “0" 304

3. Value is “Space Filled” 303

CLAIMS FILES

Data Element Name: SUBMITTER-ID

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to the CMS HETS 270/271 system.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(12) “UZZ5”

Error Condition Resulting Error Code

1. Value = "999999999999" 301

2. Value = “000000000000" 304

3. Value is “Space Filled” 303

4. Value <> "888888888888" AND SERVICE-CODE-FLAG = 88 306

CLAIM FILE

Data Element Name: THIRD-PARTY-COINSURANCE-AMOUNT-PAID

Definition: The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If the field is not applicable, enter all 8s..

If the field is applicable, but the amount is unknown, enter all 9s.

Valid Values Code Definition

S9(11)V99 000000002002E

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = "999999999999" 301

CLAIM FILE

Data Element Name: THIRD-PARTY-COINSURANCE-DATE-PAID

Definition: The date the third party paid the coinsurance amount.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If it is unknown when the request was submitted, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

CLAIM FILE

Data Element Name: THIRD-PARTY-COPAYMENT-AMOUNT

Definition: The date the third party paid the copayment amount.

Field Description:

COBOL Example

PICTURE Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements:

If the field is not applicable, enter all 8s..

If the field is applicable, but the amount is unknown, enter all 9s.

Valid Values Code Definition

S9(11)V99 000000002002E

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = "999999999999" 301

CLAIM FILE

Data Element Name: THIRD-PARTY-COPAYMENT-DATE-PAID

Definition: The date the third party paid the copayment amount.

Field Description:

COBOL Example

PICTURE Value

9(08) 20090531

Coding Requirements: Required

Date format should be CCYYMMDD (National Data Standard).

If not applicable enter all 8s.

If it is unknown when the request was submitted, enter all 9s.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

2. Value = 99999999 - 301

3. Value is not a valid date - 102

CLAIMS FILES

Data Element Name: TOOTH-NUM

Definition: CLAIMOT - The Universal/National System for permanent (adult) dentition (1-32).

COBOL Error Example

PICTURE Tolerance Value

X(02) 18

This follows the "Universal/National" system that is commonly used in the U.S. This system is identified as code set "JP" on dental claim forms and on HIPAA standard electronic dental claim transactions.

Source: "Current Dental Terminology, CDT 2009 - 2010", American Dental Association

Permanent Dentition:

Primary Dentition:

Error Condition Resulting Error Code

1. Value = "9-filled if unknown" 301

2. Value is “Space-filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: TOOTH-QUAD-IND

Definition: CLAIMOT The area of the oral cavity is designated by a two-digit code

COBOL Error Example

PICTURE Tolerance Value

X(02) 30

Coding Requirements: Required

Source: American Dental Association .

Valid Values Code Definition

10 upper right quadrant

20 upper left quadrant

30 lower left quadrant

40 lower right quadrant

Error Condition Resulting Error Code

1. Value = "9 filled if unknown" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: TOOTH-SURFACE-IND

Definition: CLAIMOT The area of the oral cavity is designated by a two-digit code

COBOL Error Example

PICTURE Tolerance Value

X(02) 04

Coding Requirements: Required

Source: American Dental Association .

Valid Values Code Definition

01 Buccal or Facial or labial — This is the tooth surface that faces the outside of your mouth. It's also what people can see when they look at you. The tooth surface that is closest or next to your cheek is called the buccal surface. In teeth that are closer to the front of the mouth, this surface is closer to the lips and is called the labial surface. Facial is an "umbrella" term that refers to both the buccal and labial surfaces.

02 Lingual or palatal — This is the surface of a tooth that is closest or next to your tongue. On your upper teeth, this is called the palatal surface. On your lower teeth, it's called the lingual surface.

03 Mesial and distal — The mesial and distal surfaces are the sides that come into contact with adjacent teeth. They are also called proximal surfaces. The mesial side faces the front of the mouth. The distal side faces the back of the mouth.

04 Occlusal — You might think of this as the "top" of a tooth. It's the surface of the back (molar and premolar) teeth that is used for biting or chewing.

05 Cusps — The parts of the occlusal surface that are raised.

06 Grooves — The parts of the occlusal surface that are indented.

07 Furcation — The part of the tooth where the roots come together. This area usually is under the gum and bone. Front teeth do not have furcations since they have only one root.

Error Condition Resulting Error Code

1. Value = "99 filled if unknown" 301

2. Value is “Space Filled” 303

3. Value is 0-filled 304

CLAIMS FILES

Data Element Name: TOT-ALLOWED-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

CLAIMS FILES

Data Element Name: TOT-CHARGED-AMOUNT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The total charge for this claim at the claim header level as submitted by the provider.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 301

CLAIMS FILES

Data Element Name: TOT-COPAY-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX – The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

CLAIMS FILES

Data Element Name: TOT-MEDICAID-PAID-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicaid on this claim or adjustment at the claim header level.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

If invalid or unknown, fill with 9999999999999.

TYPE-OF-CLAIM = 3 (encounter): If MEDICAID had no liability for the bill, 0-fill. Amount Paid should reflect the actual amount paid by Medicaid. It is not intended to reflect fee-for-service equivalents, we have provided a separate field for that. If the claim contains the amount paid to a provider by a plan, please put that payment to the AMOUNT CHARGED field.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

3. Value < +0000000000000 AND ADJUSTMENT-INDICATOR = {0, 2 or 4} 607

4. Value > +0000000000000 AND ADJUSTMENT-INDICATOR = {1,3}…………………………………607

CLAIMS FILES

Data Element Name: TOT-MEDICARE-COINS-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary’s Medicare coinsurance.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

For Crossover claims with no coinsurance payment, fill with 0000000000000.

For Crossover claims with missing or invalid coinsurance amounts, fill with 9999999999999.

For TYPE-OF-CLAIM = 3 (encounter record) fill with 8888888888888.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = 8888888888888

2. Value = 9999999999999 - 301

3. Value <> 8888888888888 AND (MEDICARE-DEDUCTIBLE-PAYMENT = 306

8888888888888 OR TYPE-OF=SERVICE = 13 OR TYPE-OF-CLAIM = 3)

4. Value = +99998 AND MEDICARE-DEDUCTIBLE-AMOUNT = (+0, +999998) 515

5. Value > AMOUNT-CHARGED 606

6. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

7. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: TOT-MEDICARE-DEDUCTIBLE-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicaid/ CHIP, on this claim at the claim header level, toward the beneficiary’s Medicare deductible.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

If claim is not a Crossover claim, or if a type of claim 3 (encounter claim) fill with +88888.

If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount and code +99998 in MEDICARE-COINSURANCE-PAYMENT.

For Crossover claims with no Medicare deductible payment, fill this field with +00000.

For Crossover claims with missing or invalid deductible amounts, fill this field with +99999.

Error Condition Resulting Error Code

1. Value is Non-Numeric - 810

OR Value = -88888

2. Value = +99999 - Reset to all 0's 301

3. Value <> +88888 AND VALUE<> +00000 AND TYPE-OF=SERVICE = {05 or 07} 306

4. Value > AMOUNT-CHARGED 510

5. Value < +00000 AND ADJUSTMENT -INDICATOR = {0, 2, or 4} 607

6. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: TOT-TPL-AMT

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a State plan..This is the total amount denoted at the claim header level paid by the third party.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

CLAIMS FILES

Data Element Name: ME

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(11)V99 000000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000000002002E”.

The actual value of -200.25 will be stored as the value of “000000002002N”.

Coding Requirements: Required.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 9999999999999 - 301

CLAIMS FILES

Data Element Name: TYPE-OF-BILL

Definition: CLAIMIP, CLAIMLT, CLAIMOT - A three-digit numeric code which identifies the specific type of bill (inpatient, outpatient, adjustments, voids, etc.). The first digit represents Type of Facility, the second digit the Bill Classification, and the third digit the Frequency. The first and second positions are separated from the third by the qualifier (CLM05-2, "A").

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(03) 123

Coding Requirements: Required.

Valid Values 1st Digit – Type of Facility				Code Definition
	1	Hospital
	2	Skilled Nursing Facility
	3	Home Health
	4	Christian Science (Hospital)
	5	Christian Science (Extended Care)
	6	Intermediate Care
	7	Clinic
	Code	2nd Digit – Bill Classifications (Excluding Clinics & Special Facilities)
	1	Inpatient
	3	Outpatient
	4	Other (For Hospital Referenced Diagnostic Services, or Home Health Not Under a Plan of Treatment)
	5	Intermediate Care, Level I
	6	Intermediate Care, Level II
	7	Intermediate Care, Level III
	8	Swing Beds
	2nd Digit – Bill Classifications (Clinics Only)
	1		Rural Health
	2		Hospital Based or Independent Renal Dialysis Center
	3		Free Standing
	4		Other Rehabilitation Facility (ORF)
	9		Other
	2nd Digit – Bill Classifications (Special Facility Only)
	1		Hospice (Non-Hospital Based)
	2		Hospice (Hospital Based)
	3		Ambulatory Surgery Center (ASC)
	4		Freestanding Birthing Center
			3rd Digit – Frequency
	1		Admit through Discharge Claim
	2		Interim – First Claim
	3 Interim – Continuing Claims
	4 Interim – Last Claim
	5 Late Charge only
	6 Adjustment of Prior Claim
	7 Replacement of Prior Claim
	8 Void/Cancel of Prior Claim

Error Condition Resulting Error Code

1. Value is Non-Numeric - 812

2. Value = 9 301

3. Value is not included in the list of valid codes 201

4. Value = 4 AND first byte of MSIS-IDENTIFICATION-NUMBER <> “&" 522

5. Value<>4 AND first byte of MSIS-IDENTIFICATION-NUMBER = “&”................................................................522

CLAIMS FILES

Data Element Name: TYPE-OF-CLAIM

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A code indicating what kind of payment is covered in this claim.

Field Description:

COBOL Example

PICTURE Value

X(01) A

Coding Requirements: Required.

Valid Values Code Definition

A A Current Fee-For-Service Claim for medical services

B Capitated Payment

C Encounter (a.k.a. “Dummy”) record that simulates a bill for a service rendered to a patient covered under some form of Capitation Plan. This includes billing records submitted by providers to non‑State entities (e.g., MCOs, health plans) for which the State has no financial liability since the at‑risk entity has already received a capitated payment from the State.

D A "Service Tracking Claim" (a.k.a. “Gross Adjustment”) that documents services received by an individual patient, when the State accepts a lump sum bill from a provider that covered similar services delivered to more than one patient, such as group screening for EPSDT.

E Supplemental Payment (above capitation fee or above negotiated rate) (e.g., FQHC additional reimbursement)

F CHIP (Title XXI) claim: A current Fee-for-Service Claim

G CHIP (Title XXI) claim: Capitated Payment

I CHIP (Title XXI) encounter record that simulates a bill for a service or items rendered to a patient covered under some form of Capitation Plan. This includes billing records submitted by providers to non-State entities (e.g., MCO’s, health plans) for which a state has no financial liability as the at-risk entity has already received a capitated payment from the state

J CHIP (Title XXI) claim for a "Service Tracking Claim" (a.k.a. “Gross Adjustment”) that documents services received by an individual patient, when the State accepts a lump sum bill from a provider that covered similar services delivered to more than one patient, such as group screening for EPSDT.

K CHIP (Title XXI) claim for a supplemental payment (above capitation fee or above negotiated rate) (e.g., FQHC additional reimbursement)

9 Unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Value = 9 301

3. Value is not included in the list of valid codes 201

4. Value = 4 or E and first byte of MSIS-IDENTIFICATION-NUMBER <>”&” ………………….. 522

5. Value <>4 or E and first byte of MSIS-IDENTIFICATION-NUMBER= “&”………………………..522

CLAIMS FILES

Data Element Name: TYPE-OF-HOSPITAL

Definition: CLAIMIP, - This code denotes the type of hospital on the claim.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) 01

Coding Requirements: Required.

Valid Values Code Definition

00 Not a hospital

Inpatient Hospital
Outpatient Hospital
Critical Access Hospital
Swing Bed Hospital
Inpatient Psychiatric Hospital
IHS Hospital
Childrens Hospital
Other

Unknown

Error Condition Resulting Error Code

1. Value is Non-Numeric 812

2. Value not included in the list of valid codes 201

CLAIMS FILES

Data Element Name: TYPE-OF-SERVICE

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A code indicating the type of service being billed. Refer to Attachment 4 for information on the various types of service.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(02) 05

Coding Requirements: Required.

Valid Values Code Definition

01 Inpatient Hospital

02 Mental Hospital Services for the Aged

03 Disproportionate Share Hospital (DSH)

04 Inpatient Psychiatric Facility Services for Individuals Age 21 Years and Under

05 ICF Services for the Mentally Retarded

07 NF'S - All Other

08 Physicians

09 Dental

10 Other Practitioners

11 Outpatient Hospital

12 Clinic

13 Home Health

15 Lab and X-Ray

16 Prescribed Drugs

19 Other Services

20 Capitated Payment s to HMO, HIO or PACE Plan

21 Capitated Payments to Prepaid Health Plans (PHPs)

22 Capitated Payments for Primary Care Case Management (PCCM)

23 Capitated Payments for Private Health Insurance

24 Sterilizations

25 Abortions

26 Transportation Services

30 Personal Care Services

31 Targeted Case Management –

33 Rehabilitation Services

34 PT, OT, Speech, Hearing Language

35 Hospice Benefits

36 Nurse Midwife Services

37 Nurse Practitioner Services

38 Private Duty Nursing

39 Religious Non-Medical Health Care Institutions

40 Supplemental Payment – Inpatient

41 Supplemental Payment – Nursing

42 Supplemental Payment – Outpatient

51 Durable Medical Equipment and Supplies (including emergency response systems

and home modifications NEW)

52 Residential Care (NEW)

53 Psychiatric services (excluding adult day care NEW)

54 Adult Day Care (NEW)

60 Indian Health Service (IHS) – Family Plan

61 Indian Health Service (HIS) – BCC

62 Indian Health Service (IHS) - BIP

99 Invalid or unknown codes

NOTE: The following codes are currently not used: 03, 06, 14, 17, 18, 27-29, 32, 40-50, 55-98. Type of Service “53” code should only be used to report outpatient psychiatric and psychiatric physician services, regardless of their age.

CLAIMS FILES

Data Element Name: TYPE-OF-SERVICE (continued)

Valid Values for Each File Type

CLAIMIP Files may contain TYPE-OF-SERVICE Values: 01, 24, 25, or 39

CLAIMLT Files may contain TYPE-OF-SERVICE Values: 02, 04, 05 or 07

CLAIMOT Files may contain TYPE-OF-SERVICE Values: 08-13, 15, 19-26, 30, 31, 33-38,

51 – 54.

CLAIMRX Files may contain TYPE-OF-SERVICE Value: 16 or 19

Error Condition Resulting Error Code

1. Value is Non-Numeric - 812

2. Value = 99 301

3. Value < 01 OR Value > 39 OR = {03, 06, 14, 17, 18, 27, 28, 29, 32} 201

4. Value <> {01, 24, 25 or 39} AND FILE-NAME = "CLAIMIP" 516

5. Value <> {02, 04, 05 or 07} AND FILE-NAME = "CLAIMLT" 516

6. Value <> {08 through 13 OR 15 OR 19 through 23 OR 516

26 OR 30 OR 31 OR 33 through 38 or 51 through 54}

AND FILE-NAME = "CLAIMOT"

7. Value <> {16 OR 19} AND FILE-NAME = “CLAIMRX” 516

8. Value = {20, 21, 22 , 23} AND TYPE-OF-CLAIM <> {2 OR 5} 518

Note: All claims for inpatient psychiatric care provided in a separately administered psychiatric wing or psychiatric hospital are included in the CLAIMLT file.

CLAIMS FILES

Data Element Name: REVENUE-CHARGE

Definition: CLAIMIP - The total charge for the related UB-04 Revenue Code (REVENUE-CODE) for the billing period. Total charges include both covered and non covered charges (as defined by UB-04 Billing Manual, form locator 47)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(8)V99 000002002E

The money fields or any numeric fields with signs will be entered as below. For an example,

The actual value of +200.25 will be stored as the value of “000002002E”.

The actual value of -200.25 will be stored as the value of “000002002N”.

Coding Requirements: Conditional.

If the amount is missing or invalid, fill with +0000000000.

Enter charge for each UB-04 Revenue Code listed on the claim

The sum of charges (REVENUE -CHARGE) must be less than or equal to AMOUNT-CHARGED.

If TYPE-OF-CLAIM = 3 (encounter record) enter the charge amount if available. If not available, fill with +0000000000.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value = +99999999 301

3. Value <> +88888888 AND corresponding REVENUE-CODE Value = 8888 306

4. Value = +88888888 AND corresponding REVENUE-CODE Value < > 8888 305

5. Value < 0 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

6. Sum of (UB-REV-CHARGE) 510

> AMOUNT-CHARGED

CLAIMS FILE

Data Element Name: REVENUE-CODE

Definition: CLAIMIP, CLAIMOT - “A code which identifies a specific accommodation, ancillary service or billing calculation” (as defined by UB-04 Billing Manual, form locator 42)

Field Description:

COBOL Error Example

PICTURE Tolerance Value

9(04) 202

Coding Requirements: Conditional.

Only valid codes as defined by the “National Uniform Billing Committee” should be used.

Enter all UB-04 Revenue Codes listed on the claim.

Value must be a valid code.

If Value invalid, record it exactly as it appears in the State system. Do not 9-fill.

If Value is unknown, fill with 9999.

Error Condition

Resulting Error Code

1. Value is Non-Numeric 810

2. Value = 0000 304

3. Value = 9999 301

4. Array range should not contain imbedded 8-filled fields (e.g., once an 8-filled field 306

appears, remaining fields should also be 8-filled)

5. No accommodation revenue code (100-219) exists within array of values, 520

AND MEDICAID-COVERED-INPATIENT-DAYS not {0, +88888}

CLAIMS FILE

Data Element Name: REVENUE-UNITS

Definition: CLAIMIP - Units associated with UB-04 Revenue Code fields (REVENUE-CODE. “A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, miles, pints of blood , or renal dialysis treatments, etc.” (as defined by UB-04 Billing Manual, form locator 46).

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(7) +0000007

Coding Requirements: Conditional.

Enter units for each UB-04 Revenue Code listed on the claim

If Value is unknown, fill with +9999999.

Error Condition Resulting Error Code

1. Value in one or more fields is Non-Numeric 810

2. Value in one or more field = +9999999 301

3. Value = +8888888 AND corresponding REVENUE-CODE (1-23) <> 8888 305

4. Value <> +8888888 AND corresponding REVENUE-CODE-(1-23) = 8888 306

5. Value < 0 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

CLAIMS FILES

Data Element Name: UNITS-ACTUAL

Definition: CLAIMOT, CLAIMRX – Number of actual units administered/used in miles, time, services, oxygen volume, drug dose, etc.

UNITS-ACTUAL: CLAIMRX

UNITS-ACTUAL-1 through UNITS-ACTUAL-5: CLAIMOT

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(03)V99 02345

Coding Requirements: Required.

NOTE==> One prescription for 100 250‑milligram tablets results in QUANTITY‑OF‑SERVICE=100.

Prior to fiscal year 1998, one prescription for 100 tablets resulted in QUANTITY‑OF‑SERVICE=1.

This field is not applicable for institutional services, dental services, laboratory and x-ray services, premium payments, or miscellaneous services (includes claims with TYPES-OF-SERVICE 09, 15, 19, 20, 21, 22,23). Fill with +000000 for these types of services. If invalid or missing, fill with +00000.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = -88888

2. Value = +99999 301

3. Value <> +88888 AND TYPE-OF-SERVICE = {09, 15, 306

19, 20, 21, 22}

4. Value = +88888 AND (TYPE-OF-SERVICE = {08, 305

10 through 14, 16, or 18} AND TYPE-OF-CLAIM = {1 or 2})

5. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

6. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: UNITS-ALLOWED

Definition: CLAIMOT, CLAIMRX – The maximum allowable number of unit’s miles, time, services, oxygen volume, drug dose, etc.

UNITS-ALLOWED: CLAIMRX

UNITS-ALLOWED-1 through UNITS-ALLOWED-5: CLAIMOT

Field Description:

COBOL Error Example

PICTURE Tolerance Value

S9(03)V99 12345

Coding Requirements: Required.

NOTE==> One prescription for 100 250‑milligram tablets results in QUANTITY‑OF‑SERVICE=100.

Prior to fiscal year 1998, one prescription for 100 tablets resulted in QUANTITY‑OF‑SERVICE=1.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

OR Value = -88888

2. Value = +99999 301

3. Value <> +88888 AND TYPE-OF-SERVICE = {09, 15, 306

19, 20, 21, 22}

4. Value = +88888 AND (TYPE-OF-SERVICE = {08, 305

10 through 14, 16, or 18} AND TYPE-OF-CLAIM = {1 or 2})

5. Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} 607

6. Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} 607

CLAIMS FILES

Data Element Name: WAIVER-ID

Field specifying the waiver or demonstration for which an eligible individual is enrolled and under which this particular claim is submitted. These IDs must be the approved, full federal waiver ID number assigned during the State submission and CMS approval process. The categories of demonstration and waiver programs include: 1915(b)(1) ; 1915(b)(2) ; 1915(b)(3) and 1915(b)(4) managed care waivers; 1915(c) home and community based services waivers; combined 1915 (b) and 1915(c) managed home and community based services waivers and 1115 demonstrations.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(20) “000000000000000000C1”

Please fill in the WAIVER-ID applicable for this service rendered/claim submitted.

Enter the WAIVER-ID number assigned by the State, and approved by CMS.

If individual is not enrolled in a waiver, or service does not fall under a waiver, 8-fill field.

Error Condition Resulting Error Code

Value is ”SPACE FILLED”…………………………………………………………………………………303

2. Value is not 8-filled AND corresponding WAIVER-TYPE = 00 or 88 538

3. Value is 8-filled AND corresponding WAIVER-TYPE = 01 THROUGH 09 or 99 538

CLAIMS FILES

Data Element Name: WAIVER-TYPE

Definition: Code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted.

Field Description:

COBOL Error Example

PICTURE Tolerance Value

X(02) “03”

Coding Requirements: Required.

Value must correspond to associated WAIVER-ID.

Valid Values Code Definition

00 Not Eligible – The individual was not eligible for Medicaid

01 1115 demonstration – Such waivers may also be called a research, experimental, demonstration or pilot waiver or refer to consumer-directed care or expanded eligibility. It may cover the entire state or just a geographic entity or specific population.

02 1915(b)(1) – These waivers permit freedom-of-choice or mandatory managed care with some voluntary managed care.

03 1915(b)(2) – These waivers allow states to use enrollment brokers.

04 1915(b)(3) – These waivers allow states to use savings to provide additional services that are not in the State Plan.

05 1915(b)(4) – These waivers allow fee for service selective contracting.

06 1915(c) – These waivers may also be called 2176, Home and Community Based Care, HCBS, HCB, and will often mention specific populations such as MR/DD, aged, disabled/physically disabled, aged/disabled, AIDS/ARC, mental health, TBI/head injury, special care children/technology dependent children.

07 Concurrent 1915(b)(c) – A concurrent HCBS/1915(c) waiver is one where the approved waiver services are delivered through a managed care authority – e.g., 1115(a), 1915(a), 1915(b), or 1932(a)

08 HIFA Waiver – The associated Waiver-ID is for a HIFA (Health Insurance and Flexibility and Accountability) waiver. May also be called demonstration waiver or refer to the eligibility expansion.

09 Pharmacy Waiver – The associated Waiver-ID is for Pharmacy waiver coverage. Includes waivers under 1115 demonstration authority which are primarily intended to increase coverage or expand eligibility for pharmacy benefits. The associated Waiver-ID is for another type of waiver.

10 Disaster-Related Waiver – The associated Waiver-ID is for a disaster-related waiver that allows for coverage related to a hurricane or other disaster.

11 Family Planning-ONLY waiver – The associated Waiver-ID-Number is for a Family Planning-ONLY waiver. In these waivers, the beneficiary’s Medicaid-covered benefits are restricted to Family Planning Services.

88 Not Applicable - The individual is eligible for Medicaid, but is NOT enrolled in a waiver.

99 Unknown – The associated Waiver-ID is for an unknown type of waiver.

Error Condition Resulting Error Code

1. Value is 99-filled 301

2. Value is not valid 203

PROVIDER FILE

Provider is defined as an entity that can be an individual person rendering services, an affiliation of individuals to form group, or an affiliation of groups to form a supergroup.

PROVIDER FILE

Data Element Name: APPL-DATE

Definition:

The date on which the provider applied for enrollment into the State’s Medicaid program.

Field Description:

	COBOL PICTURE	Example Value

	9(8)	20090531

5.	<NEW> APPL-DATE must be <= DATE-FILE-CREATED [T-MSIS’ Provider Header].

PROVIDER FILE

Data Element Name: BED-ICF-MR-NUM

Definition:

The number of beds available for Medicaid patients in an Intensive Care Facility.

Field Description:

	COBOL PICTURE		Example Value

	9(5)		100

Coding Requirements: N/A

Error Condition

Resulting Error Code

1.	<NEW> BED-ICF-MR-NUM must be <= "00000" and >= "99999".

2.	<NEW> If BED-ICF-MR-NUM is > "00000", then BEDS-NF-NUM, BED-T18-SNF-NUM, AND BED-INPATIENT-NUM must = "00000".

PROVIDER FILE

Data Element Name: BED-ICF-MR-EFF-DATE

Definition:

Effective date the facility makes beds available for Medicare/Medicaid patients in an Intensive Care Facility.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric -	810

2.	Value is 99999999 -	301

3.	Value is not a valid date	102

4.	<NEW> BED-EFF-DATE must be >= 19650730.

PROVIDER FILE

Data Element Name: BED-INPATIENT-NUM

Definition:

The number of beds available for Medicaid patients in an Inpatient Facility.

Field Description:

	COBOL PICTURE		Example Value

	9(5)		100

Coding Requirements: N/A

Error Condition

Resulting Error Code

1.	<NEW> BED-INPATIENT-NUM must be >= "00000" and <= "99999".

2.	<NEW> If BED-INPATIENT-NUM is > "00000", then BEDS-NF-NUM, BED-T18-SNF-NUM, AND BED-ICF-MR-NUM must = "00000".

PROVIDER FILE

Data Element Name: BED-INPATIENT-EFF-DATE

Definition:

Effective date the facility makes beds available for Medicare/Medicaid patients in an Inpatient Facility.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

4.	<NEW> BED-EFF-DATE must be >= 19650730.

PROVIDER FILE

Data Element Name: BED-NF-NUM

Definition:

The number of beds available for Medicaid patients in a Nursing Facility.

Field Description:

COBOL PICTURE	Error Tolerance	Example Value

9(5)		100

Coding Requirements: N/A

Error Condition

Resulting Error Code

1.	<NEW> BEDS-NF-NUM must be >= "00000" and <= "99999".

2.	<NEW> If BEDS-NF-NUM > "00000", then BED-T18-SNF-NUM, BED-ICF-MR-NUM, AND BED-INPATIENT-NUM must = "00000".

PROVIDER FILE

Data Element Name: BED-NF-EFF-DATE

Definition:

Effective date the facility makes beds available for Medicare/Medicaid patients in a Nursing Facility.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

4.	<NEW> BED-EFF-DATE must be >= 19650730.

PROVIDER FILE

Data Element Name: BED-T18-SNF-NUM

Definition:

The number of beds available for Medicaid patients in a Skilled Nursing Facility.

Field Description:

	COBOL PICTURE		Example Value

	9(5)		100

Coding Requirements: N/A

Error Condition

Resulting Error Code

1.	<NEW> BED-T18-SNF-NUM must be >= "00000" and <= "99999".

2.	<NEW> If BED-T18-SNF-NUM is > "00000", then BEDS-NF-NUM, BED-INPATIENT-NUM, AND BED-ICF-MR-NUM must = "00000".

PROVIDER FILE

Data Element Name: BED-T18-SNF-EFF-DATE

Definition:

Effective date the facility makes beds available for Medicare/Medicaid patients in a Skilled Nursing Facility.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

4.	<NEW> BED-EFF-DATE must be >= 19650730.

PROVIDER FILE

Data Element Name: BENEFIT-TYPE(1) THRU (50)

Definition:

Effective date the facility makes beds available for Medicare/Medicaid patients in a Skilled Nursing Facility.

Field Description:

	COBOL PICTURE		Example Value

	X(2)		76

Coding Requirements:

Field value is NUMERIC and maps to a valid value code set.

If a valid Benefit Type is not available, then fill this field with SPACES..

Valid Values

Benefit Type

1. Inpatient Hospital Services

2. Outpatient Hospital Services

3. Rural health clinic services

4. FQHC services

5. Laboratory and x-ray services

6. Nursing Facility Services for 21 and over

7. EPSDT

8. Family Planning Services

9. Physicians' Services

10. Medical and Surgical Services Furnished by a Dentist

11. Medical care and any type of remedial care recognized under State law - Podiatrists' Services

12. Medical care and any type of remedial care recognized under State law - Optometrists' Services

13. Medical care and any type of remedial care recognized under State law - Chiropractors' Services

14. Medical care and any type of remedial care recognized under State law - Other Practitioners' Services within scope of practice as defined by State law

15. Home Health Services - Intermittent or part-time nursing services provided by a home health agency

16. Home Health Services - Home health aide services provided by a home health agency

17. Home Health Services - Medical supplies, equipment, and appliances suitable for use in the home

18. Home Health Services - Physical therapy; occupational therapy; speech pathology; audiology provided by a home health agency

19. Private duty nursing services

20. Clinic Services

21. Dental Services

22. Physical Therapy and Related Services - Physical Therapy

23. Physical Therapy and Related Services - Occupational Therapy

24. Physical Therapy and Related Services - Services for individuals with speech, hearing and language disorders

25. Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Prescribed Drugs

26. Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Dentures

27. Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Prosthetic Devices

28. Prescription drugs, dentures, and prosthetic devices; and eyeglasses - Eyeglasses

29. Other diagnostic, screening, preventive, and rehabilitative services - Diagnostic Services

30. Other diagnostic, screening, preventive, and rehabilitative services - Screening Services

31. Other diagnostic, screening, preventive, and rehabilitative services - Preventive Services

32. Other diagnostic, screening, preventive, and rehabilitative services - Rehabilitative Services

33. Services for individuals over age 65 in IMDs - Inpatient hospital services

34. Services for individuals over age 65 in IMDs - Nursing facility services

35. Intermediate Care Facility Services for individuals with mental retardation or persons with related conditions

36. Inpatient psychiatric facility services for under 22

37. Nurse-midwife services

38. Hospice Care

39. Case Management Services and TB related services - Case management services as defined in the State Plan in accordance with section 1905(a)(19) or 1915(g)

40. Case Management Services and TB related services - Special TB related services under section 1902(z)(2)

41. Special sickle-cell anemia-related services

42. Extended services for pregnant women - Additional Pregnancy-related and postpartum services for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60th day falls.

43. Extended services for pregnant women - Additional Services for any other medical conditions that may complicate pregnancy

44. Ambulatory prenatal care for pregnant women furnished during a presumptive eligibility period

45. Respiratory care services under 1902(e)9)(A) through (C)

46. Certified pediatric or family nurse practitioners' services

47. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Transportation

48. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Services provided in religious non-medical health care facilities

49. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Nursing facility services for patients under 21

50. Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Emergency hospital services

51. Home and Community Care for Functionally Disabled Elderly individuals as defined and described in the State Plan

52. Personal care services in recipient's home

53. Emergency services for certain legalized aliens and undocumented aliens

55. Licensed or Otherwise State-Approved Free-Standing Birthing Center

56. Primary care case management services

57. Community First Choice

59. Homemaker

60. Home Health Aide

61. Personal Care Services

62. Adult Day Health services

63. Habilitation

64. Habilitation: Residential Habilitation

65. Habilitation: Supported Employment

66. Habilitation: Education (non IDEA available)

67. Habilitation: Day Habilitation

68. Habilitation: Pre-Vocational

69. Habilitation: Other Habilitative Services (describe below)

70. Respite

71. Day Treatment (mental health service)

72. Psychosocial rehabilitation

73. Environmental Modifications (Home Accessibility Adaptations)

74. Vehicle Modifications

75. Non-Medical Transportation

76. Special Medical Equipment (minor assistive Devices)

77. Home Delivered meals

78. Assistive Technology (i.e., communication devices)

79. Personal Emergency Response (PERS)

80. Nursing Services

81. Community Transition Services

82. Adult Foster Care

83. Day Supports (non-habilitative)

84. Supported Employment

85. Supported Living Arrangements

86. Private Duty Nursing

87. Supports for Consumer Direction (Supports Facilitation)

88. Participant Directed Goods and Services

89. Senior Companion (Adult Companion Services)

90. Assisted Living

91. Other

Error Condition

Resulting Error Code



1.	Value is not in the valid values list.

PROVIDER FILE

Data Element Name: BILLING-LOC-ADDR-LN1 THRU BILLING-LOC-ADDR-LN3 (1) THRU (20)

Definition:

The actual billing location of the provider including the street name and number, room or suite number or letter.

Field Description:

COBOL PICTURE	Error Tolerance	Example Value

X(28)		"123, Any Lane"

Coding Requirements:

Required

Line 1 is required and the other two lines can be blank.

Error Condition

Resulting Error Code

1.	Value = "9 filled if unknown"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: BILLING-LOC-CITY (1) THRU (20)

Definition:

The city of the billing entity responsible for billing a patient for healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"Baltimore"

Coding Requirements:

Required

Error Condition

Resulting Error Code

1.	Value = "9 filled "	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: BILL-LOC-COUNTY (1) THRU (6)

Definition:

The FIPS county code of the billing entity responsible for billing a patient for healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(03)		"005"

Coding Requirements:

Required

County code as it appears in the state system.

Error Condition

Resulting Error Code

1.	Value = "999"	301

2.	Value is “Space Filled"	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: BILL-LOC-EMAIL (1) THRU (6)

Definition:

The email address of the billing entity responsible for billing a patient for healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"[email protected]"

Coding Requirements:

Required

Line 1 is required and the other two lines can be blank.

Error Condition

Resulting Error Code

1.	Value = "9 filled if unknown"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: BILL-LOC-FAX-NUM (1) THRU (6)

Definition:

The fax number of the billing entity responsible for billing a patient for healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(10)		(123) 456-7890

Coding Requirements:

Valid fax number including the area code.
If unknown, can be filled using 9’s

	Valid Values	Code Definition
	9999999999	Unknown

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: BILL-LOC-STATE (1) THRU (6)

Definition:

The FIPS state alpha for each U.S. state, Territory, and the District of Columbia two letter state code of the billing entity responsible for billing a patient for healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(2)		"MD"

Coding Requirements:

	Required
AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition

Resulting Error Code

1.	Value = "99"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: BILL-LOC-TELEPHONE (1) THRU (6)

Definition:

The telephone number of the billing entity responsible for billing a patient for healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(10)		(123) 456-7890

Coding Requirements:

Valid telephone number including the area code.
If unknown, can be filled using 9’s

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: BILL-LOC-ZIP-CODE (1) THRU (6)

Definition:

The Zip Code of the billing entity responsible for billing a patient for healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	9(9)		21030

Coding Requirements:

Required

Redefined as 9(05) and 9(04)
9(05) is needed If value is unknown fill with 99999
9(04) could be zero filled

Error Condition

Resulting Error Code

1.	Value = "999999999"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: BORDER-STATE-IND

Definition:

A state-defined code indicating that the provider's service location is outside of state boundries.

Field Description:

	COBOL PICTURE		Example Value

	9(1)		"1"

Coding Requirements:

	Valid Values	Code Definition
	0	Yes
	1	No
	9	State does not distinguish “border state providers”.

Error Condition

Resulting Error Code

1.	Value is 9-filled	301

2.	Relational Field in Error	995

PROVIDER FILE

Data Element Name: BUSINESS-TYPE

Definition:

A code denoting the type of business entity defined in the legal system and/or the provider’s ownership component of the business.

Field Description:

	COBOL PICTURE		Example Value

	X(2)		01

Coding Requirements:

	Valid Values	Code Definition
	01	Voluntary – Non-Profit – Religious Organizations
	02	Voluntary – Non-Profit – Other
	03	Proprietary – Individual
	04	Proprietary – Corporation
	05	Proprietary – Partnership
	06	Proprietary – Other
	07	Government – Federal
	08	Government – State
	09	Government – City
	10	Government – County
	11	Government – City-County
	12	Government – Hospital District
	13	Government – Other

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: CLIA-EFF-DATE (1) THRU (12)

Definition:

The effective date as mentioned in the CLIA (Clinical Laboratory Improvement Amendments) certificate on which the laboratory certification to accept human specimens for the purposes of performing laboratory examination or procedures begins. Certificates are issued on a biannual basis, but may be terminated sooner if the state survey agency deems it necessary. This field should be updated whenever the certificate is renewed.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with spacesspacesspaces.

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date recorded in the prescribed format	102

4.	<NEW> CLIA-EFF-DATE (1) must be <= CLIA-EXP-DATE (1).

PROVIDER FILE

Data Element Name: CLIA-EXP-DATE (1) THRU (12)

Definition:

The expiration date as mentioned in the CLIA (Clinical Laboratory Improvement Amendments) certificate on which the laboratory certification to accept human specimens for the purposes of performing laboratory examination or procedures ends. . Certificates are issued on a biannual basis, but may be terminated sooner if the state survey agency deems it necessary. This field should be updated whenever the certificate is renewed or terminated.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).
If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is not available

Error Condition

Resulting Error Code

1.	<NEW> CLIA-EXP-DATE (1) must be >= CLIA-EFF-DATE (1).

2.	<NEW> CLIA-EXP-DATE (1) must be <= CLIA-EFF-DATE (2).

3.	Value is Non-Numeric - -	810

4.	Value is 99999999 - -	301

5.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: CLIA-NUM-1 through CLIA-NUM-12

Definition:

The Clinical Laboratory Improvement Amendments (CLIA) ID of the laboratory that permits it to accept human specimens for the purposes of performing laboratory examination or procedures from an eligible recipient. A CLIA certificate and CLIA Number is required for each location where testing is performed unless one of the exceptions listed below apply. Renewal of CLIA certificates occur on a biannual basis. CLIA Numbers and effective/expiration dates should be obtained from the appropriate state survey agency.

CLIA Exceptions:

Laboratories that are not at a fixed location. These labs may be covered under the certificate of the designated primary site or home base, using its address.
Not-for-profit or federal, state or local government laboratories that engage in limited public health testing, may file a single application.

Laboratories within a hospital that are located at contiguous buildings on the same campus and under common direction may file a single application for the laboratory sites within the same physical location or street address.
Any laboratory located in a state that has a CMS approved laboratory program. (Currently, there are two states with approved programs: Washington and New York. New York has a partial exemption, so a CLIA certificate may be required.)

Any laboratory that only performs testing for forensic purposes.
Research laboratories that test human specimens but do not report patient specific results for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, individual patients.
Laboratories certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), in which drug testing is performed that meets SAMHSA guidelines and regulations. (However, a CLIA certificate is needed for all other testing conducted by a SAMHSA-certified laboratory.)

Field Description:

	COBOL PICTURE		Example Value

	X(10)		"40E1810564"

Coding Requirements:

Required

Record the value exactly as it appears in the State system.

If the laboratory is exempt for one of the CLIA exceptions listed above, populate the field with “EXEMPT.”

Error Condition

Resulting Error Code

1.

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: CLIA-TYPE (1) THRU (12)

Definition:

A code to identify the type of CLIA Certificate that has been issued by the applicable state survey agency.

Field Description:

	COBOL PICTURE		Example Value

	X(2)		"01"

Coding Requirements:

Required

	Valid Values	Code Definition
	01	Certificate of Waiver (COW) – This certificate is issued to a laboratory to perform only waived tests.
	02	Certificate for Provider-Performed Microscopy Procedures (PPM) – This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
	03	Certificate of Registration (COR) – This certificate is issued to a laboratory that enables the entity to conduct moderate or high complexity laboratory testing or both until the entity is determined by survey to be in compliance with the CLIA regulations.
	04	Certificate of Compliance (COC) – This certificate is issued to a laboratory after an inspection that finds the laboratory to be in compliance with all applicable CLIA requirements.
	05	Certificate of Accreditation (COA) – This is a certificate that is issued to a laboratory on the basis of the laboratory's accreditation by an accreditation organization approved by CMSCMSCMS.

Error Condition

Resulting Error Code

1.	The value in CLIA-NUM does not equal “EXEMPT”, and the value in CLIA-TYPE does not equal one of the valid values above.	301

PROVIDER FILE

Data Element Name:Core Based Statistical Area (CBSA) Code

Definition:

A code signifying whether the provider’s service area falls into one or more metropolitan or micropolitan statistical areas.

Metropolitan and micropolitan statistical areas (metro and micro areas) are geographic entities defined by the U.S. Office of Management and Budget (OMB). The term "Core Based Statistical Area" (CBSA) is a collective term for both metro and micro areas. A metro area contains a core urban area of 50,000 or more population, and a micro area contains an urban core of at least 10,000 (but less than 50,000) population. Each metro or micro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core.

The U.S. Office of Management and Budget (OMB) defines metropolitan or micropolitan statistical areas based on published standards. The standards for defining the areas are reviewed and revised once every ten years, prior to each decennial census. Between censuses, the definitions are updated annually to reflect the most recent Census Bureau population estimates. The current definitions are as of December 2009.

See the list of metropolitan and micropolitan areas in Appendix ???: OMB CBSA Codes and Descriptions.

Valid Values:

1 = The provider’s service area falls partially or entirely inside one or more metropolitan areas.

2 = The provider’s service area falls partially or entirely inside one or more micropolitan areas, but not within any metropolitan areas.

3 = The provider’s service area falls entirely outside of all metropolitan and micropolitan areas.

Error Condition

Resulting Error Code

1.	Value = "999999999"	301

2.	Value is “Space Filled”	303

PROVIDER FILE

Data Element Name: DATE-OF-BIRTH

Definition:

Date of birth of the provider. Applicable to individual providers only.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		01012009

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is unavailable

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

PROVIDER FILE

Data Element Name: DATE-OF-DEATH

Definition:

Date of death of the provider, if applicable. Applicable to individual providers only

Field Description:

	COBOL PICTURE		Example Value

	9(8)		01012009

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is unavailable

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value = 99999999 - -	301

3.	Relational Field in Error	999

4.	<NEW> DATE-OF-DEATH must not be > DATE-FILE-CREATED [‘T-’T-MSIS’’ Header].

PROVIDER FILE

Data Element Name: DEA-EFF-DATE

Definition:

The DEA Effective date of the provider.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).
If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is unavailable

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

4.	<NEW> DEA-EFF-DATE must be <= DEA-EXP-DATE.

PROVIDER FILE

Data Element Name: DEA-EXP-DATE

Definition:

The DEA Expiration date of the provider.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: DEA-NUM

Definition:

A DEA number is a series of numbers assigned to a health care provider (such as a medical practitioner, dentist, or veterinarian), allowing them to write prescriptions for controlled substances. Legally the DEA number is solely to be used for tracking controlled substances. The DEA number, however, is often used by the industry as a general "prescriber" number that is a unique identifier for anyone who can prescribe medication.

Field Description:

	COBOL PICTURE		Example Value

	X(9)		" AP5836727"

Coding Requirements:

Required

The first letter of the registration number denotes the registrant type. The second letter is the first letter of the registrant’s last name. (e.g., J for Jones or S for Smith), and then a computer generated sequence of seven numbers (such as AP5836727 An algorithm provides a rudimentary check that the format of the DEA Number is correct.

Error Condition

Resulting Error Code

1.	Value = "999999999"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

4.	Value = “888888888"	305
5.	DEA Number does not conform to the check-digit algorithm	???

DEA Number Check-Digit Algorithm

Step 1: add the first, third, and fifth digits of the DEA number.

Step 2: add the second, fourth, and sixth digits of the DEA number.

Step 3: multiply the result of Step 2 by two.

Step 4: add the result of Step 1 to the result of Step 3.

Then, the last digit of this sum must be the same as the last digit of the DEA number.

Example: DEA number AP5836727

Step 1: 5 + 3 + 7 = 15

Step 2: 8 + 6 + 2 = 16

Step 3: 16 * 2 = 32

Step 4: 15 + 32 = 47

Registrant type (first letter of DEA Number):

A - Deprecated (may be used by some older entities)

B - Hospital/Clinic

C - Practitioner

D - Teaching Institution

E - Manufacturer

F - Distributor

G - Researcher

H - Analytical Lab

J - Importer

K - Exporter

L - Reverse Distributor

P - Narcotic Treatment Program

R - Narcotic Treatment Program

S - Narcotic Treatment Program

T - Narcotic Treatment Program

U - Narcotic Treatment Program

X - Suboxone/Subutex Prescribing Program

Due to the large Type A (Practitioner) registrant population, the initial alpha letter "B" has been exhausted. DEA uses the alpha letter "F" as the initial character for all new registration for Type A (Practitioner) registrations."

PROVIDER FILE

Data Element Name: GENDER

Definition:

The provider's gender.

Field Description:

	COBOL PICTURE		Example Value

	X(1)		"F"

Coding Requirements:

	Valid Values	Code Definition
	F	Female
	M	Male
	U	Unknown

Error Condition

Resulting Error Code

1.	Value is Numeric - Reset to “U”	812

2.	Value is “U”	301

3.	Value is not “F”, “M”, “U”	203

PROVIDER FILE

Data Element Name: LIC-EFF-DATE (1) THRU (6)

Definition:

The effective date of the provider’s professional license. The state’s professional licensing board is the source for this information. Upon renewal, the effective and expireationexpireationexpirationexpireation dates should be updated to reflect the current licensure period. This field must include the most up-to-date license information, which should be collected from the licensure board.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is unavailable

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

4.	<NEW> LIC-EFF-DATE (1) must be <= LIC-EFF-DATE (1).

PROVIDER FILE

Data Element Name: LIC-EXP-DATE (1) THRU (6)

Definition:

The expiration date of the provider’s professional license. The state’s professional licensing board is the source for this information. Upon renewal, the effective and expireation dates should be updated to reflect the current licensure period. This field must include the most up-to-date license information, which should be collected from the licensure board.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is unavailable

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

4.	<NEW> LIC-EXP-DATE (1) must be >= LIC-EFF-DATE (1).

5.	<NEW> LIC-EXP-DATE (1) must be <= LIC-EFF-DATE (2).

PROVIDER FILE

Data Element Name: LIC-NUM (1) THRU (6)

Definition:

Provider’s professional license number authorizing practice within the State. The state’s professional licensing board is the source for this information. This field must include the most up-to-date license information, which should be collected from the licensure board.

Field Description:

	COBOL PICTURE		Example Value

	X(9)		0AN234566

Coding Requirements: N/A

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -0	810

2.	Value is 999999999 - -0	301

3.	<NEW> LIC-NUM (1) <> LIC-NUM (2), LIC-NUM (3), LIC-NUM (4), LIC-NUM (5), OR LIC-NUM (6).

PROVIDER FILE

Data Element Name: MAILING-CITY (1) THRU (6)

Definition:

The city as denoted on the mailing address of the provider.

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"Baltimore"

Coding Requirements:

Required

Error Condition

Resulting Error Code

1.	Value = "9 filled if unknown"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: MAILING-COUNTY (1) THRU (6)

Definition:

The FIPS county code indicating the county of the provider’s mailing address.

Field Description:

	COBOL PICTURE		Example Value

	X(3)		"005"

Coding Requirements:

Required

County code as it appears in the state system.

Error Condition

Resulting Error Code

1.	Value = "999"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: MAILING-LOC-ADDR-LN1 THRU MAILING-LOC-ADDR-LN3 (1) THRU (6)

Definition:

The actual mailing address of the provider where payment is mailed including the street name and number, room or suite number or letter.

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"123, Any Lane"

Coding Requirements:

Required

Line 1 is required and the other two lines can be blank.

Error Condition

Resulting Error Code

1.	Value = "9 filled if unknown"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: MAILING-STATE (1) THRU (6)

Definition:

The FIPS state alpha for each U.S. state, Territory, and the District of Columbia

code as denoted on the mailing address of the provider.

Field Description:

	COBOL PICTURE		Example Value

	X(2)		"MD"

Coding Requirements: Required

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

1.	Value = "99"

PROVIDER FILE

Data Element Name: MAILING-ZIP-CODE (1) THRU (6)

Definition:

The Zip Code as denoted on the mailing address of the provider.

Field Description:

	COBOL PICTURE		Example Value

	9(9)		21030

Coding Requirements:

Required

Redefined as 9(05) and 9(04)
9(05) is needed If value is unknown fill with 99999
9(04) could be zero filled

Error Condition

Resulting Error Code

1.	Value = "999999999"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: MEDICAID-PROV-NUM

Definition:

A proprietary state-specific provider identifier assigned by the state.

Field Description:

	COBOL PICTURE		Example Value

	X(12)		001231793000

PROVIDER FILE

Data Element Name: MEDICARE-PROV-NUM

Definition:

The Medicare Provider Number has been renamed to the CMS Certification Number in order to avoid confusion with the National Provider Identifier (NPI). (Effective October 1, 2007)

Background of Medicare Provider Number: A Unique identification number assigned by Medicare that uniquely identifies a health care provider and is used on billing forms submitted to Medicare. The Medicare Provider Number is the number assigned to the provider for billing and identification purposes. This field specifies the institution that rendered services to a beneficiary. This is the unique number issued by the HCFA regional office to a provider of services upon initial certification for participation in the Medicare program. The Medicare Provider Number has been replaced with the National Provider Identifier (NPI).

Field Description:

	COBOL PICTURE		Example Value

	X(10)		0123456789

Coding Requirements: N/A

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Data Element Name: NCPDP-EFF-DATE

Definition:

The effective date of the provider’s NCPDP number.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

	Valid Values

2.	Value is Non-Numeric - -	810

3.	Value is 99999999 - -	301

4.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: NCPDP-EXP-DATE

Definition:

The expiration date of the provider’s NCPDP number.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Valid date is not available

Error Condition

Resulting Error Code

1.	<NEW> NCPDP-EXP-DATE must be >= NCPDP-EFF-DATE.

2.	Value is Non-Numeric - -	810

3.	Value is 99999999 - -	301

4.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: NCPDP-NUM

Definition:

Each licensed pharmacy in the United States is assigned a unique seven-digit number by the National Council for Prescription Drug Programs (NCPDP), in cooperation with the National Association of Boards of Pharmacy. The purpose of this system is to enable a pharmacy to identify itself to all third-party processors by one standard number. If NCPDP is not available but NABP is available, report NABP number here.

Field Description:

	COBOL PICTURE		Example Value

	X(7)		2331673

Coding Requirements:

Required.

The NCPDP number is set up with the following format: the first two-digits from the left denote state designation corresponding to the state the in alphabetical order. The second group of four digits identify the pharmacy and are sequentially assigned from 0001 up. The last, or right most digit, is the check digit. This digit is the unit digit of the sum of the first, third and fifth digits of the NCPDP number, plus twice the sum of the second, fourth and sixth digits. For example:

Pharmacy Number Check Digit Algorithm
Example
23 3167 3 2 + 3 + 6 =11
Denotes Sequential Check (3 + 1 + 7) x 2 =22
State of Number Digit __
Michigan 33

Error Condition

Resulting Error Code

1.	Value = 9-filled	301

2.	Value = 0-filled	304

3.	Value is “Space Filled”	303

PROVIDER FILE

Data Element Name: OUT-OF-STATE-IND

Definition:

If ANY of the service locations are out of state, indicidate "Yes."

Field Description:

	COBOL PICTURE		Example Value

	9(1)		1

Coding Requirements:

Required

Valid Values

Code Definition

Yes

Unknown

Error Condition

Resulting Error Code

1.	Value = "99"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: OWNERSHIP-CODE

Definition:

A code denoting the ownership interest and/or managing control information.

Field Description:

	COBOL PICTURE		Example Value

	X(1)		"A"

Coding Requirements:

	Valid Values	Code Definition
	A	Domestic Corporation - A corporation that is registered to do business in the state in which it was originally incorporated.
	C	Professional Corporation – A legal structure authorized by state law for a fairly narrow list of licensed professions, including lawyers, doctors, accountants, many types of higher-level health providers and often architects. Unlike a regular corporation, a professional corporation does not absolve a professional for personal liability for her own negligence or malpractice. The main reason why groups of professions choose this organizational structure is that, unlike a general partnership, owners are not personally liable for the malpractice of other owners.
	E	State Employee
	F	Financial Institution
	G	Governmental Entity Local Govt Owned State Owned Federally Owned Privately Owned
	I	Individual Recipient
	L	Local Small Disadvantage Business Enterprises
	N	Medical Corporation
	O	Out of State Corporation - A corporation that is registered to do business in a state or other jurisdiction other than where it was originally incorporated. (Also referred to as a foreign corporation.)
	P	Professional Association
	R	Foreign Corporation - A corporation that is registered to do business in a state or other jurisdiction other than where it was originally incorporated. A corporation incorporated outside of the US and registered to do business in one or more US states. (Also referred to as a multinational, or overseas corporation.)
	S	Sole Proprietorship – An individual or married couple in business alone. It is simple to form and operate, and may enjoy greater flexibility of management and fewer legal controls. However, the business owner is personally liable for all debts incurred by the business.
	T	General Partnership – A General Partnership is composed of two or more persons (usually not a married couple) who agree to contribute money, labor, and/or skill to a business. Each partner shares the profits, losses, and management of the business and each partner is personally and equally liable for debts of the partnership. State Owned Privately Owned

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PER-DIEM-AMT-ICF-MR

Definition:

This field identifies the per diem amount to be paid for an individual claim for providers who are reimbursed on a per diem basis in an Intensive Care Facility. If the provider is reimbursed based on a percentage of charges, this field identifies the percentage. If per diem payment does not apply, this field shows a zero.

Field Description:

	COBOL PICTURE		Example Value

	S9(11)V99		123.45

Coding Requirements:

Required

The total per diem Medicaid pays is the sum of the following components:

Variable cost rate -The lower of the variable cost rate, the facility specific target rate, county ceiling, or the county ceiling target rate.
Property - plus the property fixed cost rate.
Buy Back of Medicaid Trend Adjustments (MTA).
Exemptions to ceilings by Low Income Pool program (LIP).

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value = 99999 - -	301

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PER-DIEM-AMT-INPATIENT

Definition:

This field identifies the per diem amount to be paid for an individual claim for providers who are reimbursed on a per diem basis in an Inpatient Facility. If the provider is reimbursed based on a percentage of charges, this field identifies the percentage. If per diem payment does not apply, this field shows a zero.

Field Description:

	COBOL PICTURE		Example Value

	S9(11)V99		123.45

Coding Requirements:

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value = 99999 - -	301

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PER-DIEM-AMT-NF

Definition:

This field identifies the per diem amount to be paid for an individual claim for providers who are reimbursed on a per diem basis in a Nursing Facility. If the provider is reimbursed based on a percentage of charges, this field identifies the percentage. If per diem payment does not apply, this field shows a zero.

Field Description:

	COBOL PICTURE		Example Value

	S9(11)V99		123.45

Coding Requirements:

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value = 99999 - -	301

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PER-DIEM-AMT-T18-SNF

Definition:

This field identifies the per diem amount to be paid for an individual claim for providers who are reimbursed on a per diem basis in a Skilled Nursing Facility. If the provider is reimbursed based on a percentage of charges, this field identifies the percentage. If per diem payment does not apply, this field shows a zero.

Field Description:

	COBOL PICTURE		Example Value

	S9(11)V99		123.45

Coding Requirements:

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value = 99999 - -	301

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PRACTICE-LOC-ADDR-LN1 THRU PRACTICE-LOC-ADDR-LN3 (1) THRU (3) <NEW>

Definition:

Address lines of provider's practice location. Include street name and number, room or suite number or letter. Up to three practice locations possible (identifies providers who may be working at multiple locations within a practice).

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"123, Any Lane"

Coding Requirements:

Practice location may be identical to provider's billing address, service address, or both.

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PRACTICE-LOC-CITY (1) THRU (3) <NEW>

Definition:

City of provider's practice location. Up to three practice locations possible (identifies providers who may be working at multiple locations within a practice).

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"Baltimore"

Coding Requirements:

Practice location may be identical to provider's billing address, service address, or both.

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PRACTICE-LOC-COUNTY (1) THRU (3) <NEW>

Definition:

FIPS county code indicating the provider's practice location. Up to three practice locations possible (identifies providers who may be working at multiple locations within a practice).

Field Description:

	COBOL PICTURE		Example Value

	X(3)		"005"

Coding Requirements:

FIPS county code as it appears in the state system.

Practice location may be identical to provider's billing address, service address, or both.

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PRACTICE-LOC-STATE (1) THRU (3) <NEW>

Definition:

FIPS state alpha for each U.S. state, Territory, and the District of Columbia.

of provider's practice location. Up to three practice locations possible (identifies providers who may be working at multiple locations within a practice).

Field Description:

	COBOL PICTURE		Example Value

	X(2)		"MD"

Coding Requirements:

Practice location may be identical to provider's billing address, service address, or both.

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition

1.	Value = "99"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: PRACTICE-LOC-ZIP-CODE (1) THRU (3) <NEW>

Definition:

Zip code of provider's practice location. Up to three practice locations possible (identifies providers who may be working at multiple locations within a practice).

Field Description:

	COBOL PICTURE		Example Value

	9(9)		21030

Coding Requirements:

Practice location may be identical to provider's billing address, service address, or both.

Redefined as 9(05) and 9(04)

9(05) is needed If value is unknown fill with 99999

9(04) could be zero filled

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PREV-MEDICAID-PROV-NUM

Definition:

A previously assigned unique identification number to Medicaid Providers - Performing, Attending and Referring Providers to be used on all claim forms.

Field Description:

	COBOL PICTURE		Example Value

	X(12)		001217930000

Coding Requirements:

Required

Error Condition

Resulting Error Code

1.	Value = "999999999999"	301

2.	Value is “Space Filled”	303

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PREV-MEDICARE-PROV-NUM

Definition:

A previously assigned unique identification number by Medicare that uniquely identifies a health care provider and is used on billing forms submitted to Medicare. The Medicare Provider Number is the number assigned to the provider for billing and identification purposes. This field specifies the institution that rendered services to a beneficiary. This is the unique number issued by the HCFA regional office to a provider of services upon initial certification for participation in the Medicare program. The Medicare Provider Number has been replaced with the National Provider Identifier (NPI)..

Field Description:

	COBOL PICTURE		Example Value

	X(10)		0123456789

Coding Requirements: N/A

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PROV-CATEGORY-OF-SERVICE (1) THRU (6)

Definition:

A code intended to represent a description of the kinds of services that the provider is allowed to render on Medicaid eligibles.

Field Description:

	COBOL PICTURE		Example Value

	9(3)		"003"

Coding Requirements:

	Valid Values	Code Definition
	001	<NEW> Physicians Services
	002	<NEW> Dental Services
	003	<NEW> Optometric Services
	004	<NEW> Podiatry Services
	005	<NEW> Chiropractic Services
	006	<NEW> Physicians Psychiatric Services
	007	<NEW> Development Therapy, Orientation and Mobility Services
	010	<NEW> Nursing Services
	011	<NEW> Physical Therapy Services
	012	<NEW> Occupational Therapy Services
	013	<NEW> Speech Therapy/Pathology Services
	014	<NEW> Audiology Services
	016	<NEW> Home Health Aids
	017	<NEW> Anesthesia Services
	018	<NEW> Midwife Services
	020	<NEW> Inpatient Hospital Services (General)
	021	<NEW> Inpatient Hospital Services (Psychiatric)
	022	<NEW> Inpatient Hospital Services (Physical Rehabilitation)
	024	<NEW> Outpatient Services (General)
	025	<NEW> Outpatient Services (ESRD)
	026	<NEW> General Clinic Services
	027	<NEW> Psychiatric Clinic Services (Type ‘A’)
	028	<NEW> Psychiatric Clinic Services (Type ‘B’)
	029	<NEW> Clinic Services (Physical Rehabilitation)
	030	<NEW> Healthy Kids Services
	031	<NEW> Early Intervention Services
	035	<NEW> Alcohol & Substance Abuse Rehab
	037	<NEW> Skilled Care – Hospital Residing
	038	<NEW> Exceptional Care – Hospital Residing
	039	<NEW> DD/MI Non-Acute Care – Hospital Residing
	040	<NEW> Pharmacy Services (Drug and OTC)
	041	<NEW> Medical Equipment/Prosthetic Devices
	043	<NEW> Clinical Laboratory Services
	044	<NEW> Portable X-Ray Services
	045	<NEW> Optical Services
	048	<NEW> Medical Supplies
	050	<NEW> Emergency Ambulance Transportation
	051	<NEW> Non-Emergency Ambulance Transportation
	052	<NEW> Medicar Transportation
	053	<NEW> Taxicab Services
	054	<NEW> Service Car
	055	<NEW> Auto Transportation (Private)
	056	<NEW> Other Transportation
	057	<NEW> Nurse Practitioner Services
	058	<NEW> Social Work
	059	<NEW> Psychologist
	060	<NEW> Home Care
	061	<NEW> General Inpatient
	062	<NEW> Continuous Care Nursing
	063	<NEW> Respite Care
	064	<NEW> Other Behavioral Health
	067	<NEW> Maternal & Child Health Application
	068	<NEW> Targeted Care Management
	081	<NEW> HMO Services
	098	<NEW> MPE Certification

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PROV-ENROLLMENT-STATUS

Definition:

Coding for the provider’s enrollement status.

Field Description:

COBOL
PICTURE

Example

Value

9(2)

Coding Requirements:

Valid Values

Code Definition

01 Term-Medicaid Authority

02 Term-Medicare Termination

03 Term-License Revoked

04 Term-License Expired

05 Term-Mcare/Mcaid Exclusion

06 Term-Change of Ownership

07 Term- No Claims Activity

08 Term-Provider Deceased

09 Pending Enrollment

10 Term-Voluntary Termination

11 Term-Involuntary Termination

20 Denied-Invalid License

21 Denied Two Prov Numbers

22 Denied Same Nbr Assigned

23 Denied Not Eligible

24 Denied For Other Reasons

40 Pending No Lic/Temp Lic

41 Pending Signed Agreement

42 Pending Missing Documentation

43 Pending Rate Determination

44 Pending Status Approval

45 Pending W9 Missing or Incomplt

46 Pend-License/Cert Verif

47 Pending NPI Invalid

60 Active

61 Active Reinstated

62 Active Do Not Pay

63 Active - Encounter Only

64 Active-Financial Trans Only

65 Active - Elig Verification

PROVIDER FILE

Data Element Name: PROV-ENROLLMENT-STATUS-EFF-DATE (1) THRU (12)

Definition:

The effective date of the provider’s enrollment status.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Valid date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: PROV-ENROLLMENT-STATUS-END-DATE (1) THRU (12)

Definition:

The end date of the provider’s enrollment status.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Valid date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: PROV-GRP-EFFECTIVE-DATE (1) THRU (100)

Definition:

The Effective date of the provider’s enrollment into the group

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Valid date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: PROV-GRP-EXPIRATION-DATE (1) THRU (100)

Definition:

The Expiration date of the provider’s enrollment into the group.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Valid date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value is 99999999 - -	301

3.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: PROV-GRP-NPI-NUM (1) THRU (100)

Definition:

The National Provider ID (NPI) of the group or entity that the individual or subpart is associated to.

Field Description:

	COBOL PICTURE		Example Value

	X(10)		"0136793000"

Coding Requirements:

Required

Record the value exactly as it appears in the State system.

If legacy identifiers are available for providers, then report the legacy IDs in the Provider ID field and the NPI in this field. If only the legacy Provider ID is available, then 9-fill the National Provider ID and enter the legacy IDs in the Provider ID fields.

8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22)

If Value is unknown, fill with "9999999999".

Error Condition

Resulting Error Code

1.	<NEW> If PROV-GRP-NPI-NUM = “8888888888" then TYPE-OF-SERVICE must equal 20, 21, or 22

2.	<NEW> If PROV-GRP-NPI-NUM <> “8888888888" then TYPE-OF-SERVICE must not equal 20, 21, or 22

3.	Value = "9999999999"	301

4.	Value is “Space Filled”	303

5.	Value is 0-filled	304

6.	Value = “8888888888" AND TYPE-OF-SERVICE <> {20, 21, 22}	305

7.	Value <> “8888888888" AND TYPE-OF-SERVICE = {20, 21, 22}	306

PROVIDER FILE

Data Element Name: PROV-GRP-NUM (1) THRU (100)

Definition:

The unique identification number assigned to the group or subpart that the individual or subpart is associated to.

Field Description:

	COBOL PICTURE		Example Value

	X(10)		“0179300 ”

Coding Requirements:

	Required
1.	Value = "9999999”	301

2.	Value is “Space Filled”	303

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PROV-STATUS-CODE (1) THRU (100)

Definition:

This field is used to list the enrollment status code of the provider in the group.

Field Description:

	COBOL PICTURE		Example Value

	X(2)		"ZZ"

Coding Requirements:

	Valid Values	Code Definition
	A	Active
	D	Deceased
	E	Recertification Date
	F	License Suspend/Revoked
	G	License not renewed
	H	Terminated by CMS
	I	Terminated by State
	J	Provider Joined Group
	K	Legal Action
	L	Duplicate Enrollment
	N	Number Changed
	O	Chg in Ownership
	P	Terminated by Provider
	R	Retired
	S	Suspended by State
	U	Terminated by not Enrolling
	Y	Inactive For One Year

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PROV-GRP-TAXONOMY (1) THRU (100)

Definition:

Standard Taxonomy codes. A code from the national Health Care Provider Taxonomy Code Set which describes the kind of provider.

Field Description:

	COBOL PICTURE		Example Value

	X(12)		"207KI0005X"

Coding Requirements: N/A

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: PROV-FIRST-NAME

Definition:

The first name of the provider when the provider is a person.

Field Description:

	COBOL PICTURE		Example Value

	X(35)		"Mickey"

Coding Requirements:

Leave blank if the provider is not a person.
Enter the first 35 characters if the first name exceeds 35 bytes

Error Condition

Resulting Error Code

1. Value is Numeric 810

2. Value = 9 301

PROVIDER FILE

Data Element Name: PROV-MIDDLE-INITIAL

Definition:

The middle initial of the provider when the provider is a person.

Field Description:

COBOL Example

PICTURE Value

X(01) “R”

Coding Requirements:

Leave blank if not available

Leave blank when the provider is not an individual.

Error Condition Resulting Error Code

1. Value is Numeric 810

2. Value = 9 301

PROVIDER FILE

Data Element Name: PROV-LAST-NAME

Definition:

The last name of the provider when the provider is a person.

Field Description:

	COBOL PICTURE		Example Value

	X(35)		"Mouse"

Coding Requirements:

Leave blank if the provider is not a person.
Enter the first 35 characters if the last name exceeds 35 bytes

Error Condition

Resulting Error Code

1. Value is Numeric 810

2. Value = 9 301

PROVIDER FILE

Data Element Name: PROV-LEGAL-NAME

Definition:

The name as it appears on the provider agreement between the state and the entity. Both persons and other entities can have a legal name.

Field Description:

	COBOL PICTURE		Example Value

	X(100)		"XYZ Orthopedics Associates"

Coding Requirements: N/A

Every provider is expected to have a legal name.

Error Condition

Resulting Error Code

1. Value is Numeric 810

2. Value = 9 301

PROVIDER FILE

Data Element Name: PROV-DOING-BUSINESS-AS-NAME

Definition:

The provider’s name that is commonly used by the public when the “doing-business-as” (`) name is different than the legal name. DBA is an abbreviation for "doing business as." Registering a DBA is required to operate a business under a name that differs from the company's legal name.

Field Description:

	COBOL PICTURE		Example Value

	X(100)		"Edgeville Orthopedics"

Coding Requirements:

Leave the field empty when the DBA name equals the legal name.

Error Condition

Resulting Error Code

1. Value is Numeric 810

2. Value = 9 301

PROVIDER FILE

Data Element Name: PROV-INACTIVE-IND

Definition:

Code which indicates if the provider is currently inactive (in terms of the provision of services to Medicaid/CHIP enrollees).

Field Description:

	COBOL PICTURE		Example Value

	9(1)		1

Coding Requirements:

	Valid Values	Code Definition
	0	Yes
	1 9	No Unknown

Error Condition

Resulting Error Code

1. Value is Non-Numeric - - 812

2. Value is ‘9’ 301

3. Value is not = ‘0’,’1’, and ‘9’’ 203

PROVIDER FILE

Data Element Name: PROV-INACTIVE-START-DATE

Definition:

Beginning date of the inactive period of the provider of services to Medicaid/CHIP enrollees.

Field Description:

COBOL
PICTURE

Example

Value

9(08) 20090531

Coding Requirements: Required if PROV-INACTIVE-IND = ‘1’ – yes.

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

PROVIDER FILE

Data Element Name: PROV-INACTIVE-END-DATE

Definition:

Ending date of the inactive period of the provider of services to Medicaid/CHIP enrollees.

Field Description:

	COBOL PICTURE	Example Value

9(08) 20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

Error Condition Resulting Error Code

1. Value is Non-Numeric 810

2. Value is 99999999 301

3. Value is not a valid date 102

PROVIDER FILE

Data Element Name: PROV-NPI-NUM (1) THRU (10)

Definition:

The National Provider ID (NPI) of the provider.

Field Description:

	COBOL PICTURE		Example Value

	X(10)		"0136793000"

Coding Requirements:

Error Condition

Resulting Error Code

1.	<NEW> If PROV-GRP-NPI-NUM = “8888888888" then TYPE-OF-SERVICE must equal 20, 21, or 22

2.	<NEW> If PROV-GRP-NPI-NUM <> “8888888888" then TYPE-OF-SERVICE must not equal 20, 21, or 22

3.	Value = "9999999999"	301

4.	Value is “Space Filled”	303

5.	Value is 0-filled	304

6.	Value = “8888888888" AND TYPE-OF-SERVICE <> {20, 21, 22}	305

7.	Value <> “8888888888" AND TYPE-OF-SERVICE = {20, 21, 22}	306

PROVIDER FILE

Data Element Name: PROV-SPECIALTY (1) THRU (6)

Definition:

This field contains the specialty code assigned by the payer and is used to standardize the specialty coding of the provider records.

Field Description:

	COBOL PICTURE		Example Value

	X(02)		“01”

Coding Requirements:

Required.

8-fill if not applicable
http://www.cms.hhs.gov/medicareprovidersupenroll/downloads/taxonomy.pdf
http://www.cms.hhs.gov/Transmittals/downloads/R1715CP.pdf

If applicable, use suggested coding below.

Valid Values Code Definition

01 General Practice

02 General Surgery

03 Allergy/Immunology

04 Otolaryngology

05 Anesthesiology

06 Cardiology

07 Dermatology

08 Family Practice

09 Interventional Pain Management

10 Gastroenterology

11 Internal Medicine

12 Osteopathic Manipulative Therapy

13 Neurology

14 Neurosurgery

16 Obstetrics/Gynecology

17 Hospice and Palliative Care

18 Ophthalmology

19 Oral Surgery (dentists only)

20 Orthopedic Surgery

21 Ambulance

22 Pathology

23 Available

24 Plastic and Reconstructive Surgery

25 Physical Medicine and Rehabilitation

26 Psychiatry

27 Available

28 Colorectal Surgery (formerly proctology)

29 Pulmonary Disease

30 Diagnostic Radiology

31 Available

32 Anesthesiologist Assistants

33 Thoracic Surgery

34 Urology

35 Chiropractic

36 Nuclear Medicine

37 Pediatric Medicine

38 Geriatric Medicine

39 Nephrology

40 Hand Surgery

41 Optometry

44 Infectious Disease

46 Endocrinology

48 Podiatry

66 Rheumatology

70 Single or Multispecialty Clinic or Group Practice

72 Pain Management

73 Mass Immunization Roster Biller

74 Radiation Therapy Center

75 Slide Preparation Facilities

76 Peripheral Vascular Disease

77 Vascular Surgery

78 Cardiac Surgery

79 Addiction Medicine

81 Critical Care (Intensivists)

82 Hematology

83 Hematology/Oncology

84 Preventive Medicine

85 Maxillofacial Surgery

86 Neuropsychiatry

90 Medical Oncology

91 Surgical Oncology

92 Radiation Oncology

93 Emergency Medicine

94 Interventional Radiology

98 Gynecological/Oncology

99 Unknown Physician Specialty

A0 Hospital

A1 Skilled Nursing Facility

A2 Intermediate Care Nursing Facility

A3 Other Nursing Facility

A4 Home Health Agency

A5 Pharmacy

A6 Medical Supply Company with Respiratory Therapist

A7 Department Store

A8 Grocery Store

B1 Air Ambulance Services

B2 Water Ambulance Services

B3 Ambulance

B4 Van

B4 Taxi

C1 Capitation Payment

Error Condition

Resulting Error Code

1.	Value = "99”	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: PROV-TAX-ID-CURRENT

Definition:

The provider’s current Employer Identification Number (EIN), also known as a Federal Tax Identification Number, used to identify the provider’s business entity.

Field Description:

	COBOL PICTURE		Example Value

	X(12)		"012345678"

Coding Requirements:

An EIN is usually written in the form 00-0000000

If EIN is missing or invalid, fill with 999999999.

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value = 999999999 - -	301

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PROV-TAX-ID-PREVIOUS

Definition:

The provider’s previous Employer Identification Number (EIN), also known as a Federal Tax Identification Number, used to identify the provider’s business entity.

Field Description:

	COBOL PICTURE		Example Value

	X(12)		"012345678"

Coding Requirements:

An EIN is usually written in the form 00-0000000

If EIN is missing or invalid, fill with 999999999.

Error Condition

Resulting Error Code

1.	Value is Non-Numeric - -	810

2.	Value = 999999999 - -	301

3.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PROV-TAXONOMY (1) THRU (6)

Definition:

Standard Taxonomy codes. A code from the national Health Care Provider Taxonomy Code Set which describes the kind of provider.

Field Description:

	COBOL PICTURE		Example Value

	X(12)		"207KI0005X"

Coding Requirements:

Required.

If Value is unknown, fill with "999999999999".

Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.

http://www.wpc-edi.com/content/view/793/1

Error Condition

Resulting Error Code

1.	Value = "999999999999"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

4.	Relational Field in Error	999

PROVIDER FILE

Data Element Name: PROV-TYPE (1) THRU (6)

Definition:

Standard provider type code.

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements: Required

Valid Values Code Definition

01 General Hospital

02 Special Hospital/Outpatient Rehabilitation Facility

03 Psychiatric Hospital

05 Community Mental Health Center

06 Pediatric Hospital

07 End Stage Renal Hospital

08 Clinic

09 Federally Qualified Community Health Clinic

10 Rural Health Clinic

11 Federally Qualified Health Center

12 Dialysis center

13 Behavioral Health Organization

14 School Based Clinic

15 IHS/Tribal Clinic

15 Adult Day Care

20 Pharmacy

25 Physician (MD)

26 Physician (DO)

27 Podiatrist

28 Chiropractor

29 Physician Assistant

30 Advanced Registered Nurse Practitioner (ARNP)

31 CRNA

32 Psychologist

34 Licensed Midwife

35 Dentist

36 Registered Nurse (RN)

37 Licensed Practical Nurse (LPN)

38 Nursing Attendant

39 Massage Therapist

41 Contract Nurse

44 Public Transportation

45 Private Transportation

46 Hospice

50 Independent Laboratory

51 Portable X-Ray Company

52 Alternative Medicine

53 Non-Medical Vendor

54 Prosthetics/Orthotics

55 Vocational Rehabilitation (Training, Tuition and Schools)

56 Vocational Rehabilitation Counselor

57 Rehabilitation Maintenance

58 Assisted Re-employment

59 Relocation Expenses

60 Audiologist/Speech Pathologist

61 Second Opinion Contractor

62 Optometrist

63 Optician

65 Home Health Agency

66 HSBS Waiver

67 Personal Care Agency

69 Birthing Center

70 HMO or MCO

71 Physical Therapist

72 Occupational Therapist

73 Pulmonary Rehabilitation

74 Outpatient Renal Dialysis Facility

75 Medical Supplies/Durable Medical Equipment (DME)

76 Case Management Agency

77 Social Worker

78 Blood Bank

79 Alternative Payee

80 Pay-to-Intermediary

81 Ambulatory Surgery Center

84 Residential Treatment

89 Federal Facility (VA Hospital)

90 Skilled Nursing Facility (SNF)-Medicare Certified

91 Skilled Nursing Facility (SNF)-Non-Medicare Certified

92 Intermediate Care Facility (ICF)

93 Rural Hospital Swing Bed

94 Boarding House

95 Insurance Company (Third Party Carriers)

96 Other Provider

97 Billing Agent

98 Lien holder

99 Unknown

Error Condition Resulting Error Code

1. Value is 99 301

2. Value is not in list of valid values ???

3. Value is 0-filled 304

PROVIDER FILE

Data Element Name: SERVICE-LOC-ADDR-LN1 THRU SERVICE-LOC-ADDR-LN3 (1) THRU (6)

Definition:

The street address of the servicing provider furnishing healthcare services. Line 1 is required and the other two lines can be blank.

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"123, Any Lane"

Coding Requirements:

Required

Line 1 is required and the other two lines can be blank.

Error Condition

Resulting Error Code

1.	Value = "9 filled if unknown"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: SERVICE-LOC-CITY (1) THRU (6)

Definition:

The city/cities, the servicing provider furnished healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"Baltimore"

Coding Requirements:

Required

Error Condition

Resulting Error Code

1.	Value = "9 filled if unknown"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: SERVICE-LOC-COUNTY (1) THRU (6)

Definition:

The FIPS county code(s) indicating the counties where the provider is providing healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	9(3)		005

Coding Requirements:

Required

FIPS county code as it appears in the state system.

Error Condition

Resulting Error Code

1.	Value = "999"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: SERVICE-LOC-EMAIL (1) THRU (6)

Definition:

The email address of the servicing provider furnishing healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(28)		"[email protected]"

Coding Requirements:

Required

Line 1 is required and the other two lines can be blank.

Error Condition

Resulting Error Code

1.	Value = "9 filled if unknown"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: SERVICE-LOC-FAX-NUM (1) THRU (6)

Definition:

The fax number of the servicing provider furnishing healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(10)		(123) 456-7890

Coding Requirements:

Valid fax number including the area code.
If unknown, can be filled using 9’s

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: SERVICE-LOC-STATE (1) THRU (6)

Definition:

The FIPS state alpha for each U.S. state, Territory, and the District of Columbia.

code(s) of the provider furnishing healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(2)		"MD"

Coding Requirements:

Required

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1	Value is not in the list of valid values …………………………………………………………………… ???

2	Value is 0-filled ……………………………………………………………………………………..	304

PROVIDER FILE

Data Element Name: SERVICE-LOC-TELEPHONE (1) THRU (6)

Definition:

The telephone number of the servicing provider furnishing healthcare services.

Field Description:

	COBOL PICTURE		Example Value

	X(10)		(123) 456-7890

Coding Requirements: Required

Error Condition

Resulting Error Code

PROVIDER FILE

Data Element Name: SERVICE-LOC-ZIP-CODE (1) THRU (6)

Definition:

Zip code in which the service location is located.

Field Description:

	COBOL PICTURE		Example Value

	9(9)		212341234

Coding Requirements: Required

Redefined as 9(05) and 9(04)
9(05) is needed If value is unknown fill with 99999
9(04) could be zero filled

Error Condition

Resulting Error Code

1.	Value = "999999999"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

PROVIDER FILE

Data Element Name: SPEC-CERT-EFF-DATE (1) THRU (6)

Definition:

The Effective date of the provider specialty code.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Valid date is not available

Error Condition

Resulting Error Code

1.	SPEC-CERT-EFF-DATE (1) must be <= SPEC-CERT-EXP-DATE (1).	???

2.	Value is Non-Numeric - -	810

3.	Value is 99999999 - -	301

4.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: SPEC-CERT-EXP-DATE (1) THRU (6)

Definition:

The Expiration date of the provider level specialty code.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Valid date is not available

Error Condition

Resulting Error Code

1.	SPEC-CERT-EXP-DATE (1) must be >= SPEC-CERT-EFF-DATE (1).	???

2.	SPEC-CERT-EXP-DATE (1) must be <= SPEC-CERT-EFF-DATE (2).	???

3.	Value is Non-Numeric -	810

4.	Value is 99999999 -	301

5.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: SSN

Definition:

The provider's social security number. Applicable to individual provider only.

Field Description:

	COBOL PICTURE		Example Value

	9(9)		253981873

Coding Requirements:

Value must represent individual provider’s SSN.,
Value should = SSN or 999999999 if the SSN is unknown.

.

Error Condition

Resulting Error Code



1.	Value is Non-Numeric	811

2.	Value is 999999999	301

PROVIDER FILE

Data Element Name: TEACHING-IND

Definition:

A code indicating if the provider’s organization is a teaching facility.

Field Description:

	COBOL PICTURE		Example Value

	9(1)		1

Coding Requirements:

Required

	Valid Values	Code Definition
	0	No
	1	Yes

Error Condition

Resulting Error Code

1.	Value = "99"	301

2.	Value is “Space Filled”	303

PROVIDER FILE

Data Element Name: TERMINATION-DATE

Definition:

The date on which the provider’s license termination became effective.

Field Description:

	COBOL PICTURE		Example Value

	9(8)		20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is not available

Error Condition

Resulting Error Code

1.	Value is Non-Numeric -	810

2.	Value is 99999999	301

3.	Value is not a valid date	102

PROVIDER FILE

Data Element Name: TERMINATION-REASON-CODE

Definition:

Indicate the reason for provider license termination.

Field Description:

COBOL Example

PICTURE Value

X(02) 01

Coding Requirements: Required

Valid Values	Code Definition
1	Non-Compliance
2	Loss of license or other State action
3	Federal exclusion/ debarment, etc.
4	State exclusion/ debarment, etc.
5	Felony conviction
6	False or misleading information
7	Onsite review/ Provider is no longer operational
8	Misuse of billing number
9	Abuse of billing privileges
10	Failure to report a change of address/ownership
11	Action Taken by Medicare
12	Action Taken by Medicaid/CHIP
13	Other
99	Unknown

Error Condition

Resulting Error Code

1.	Value = "99"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

MANAGED CARE PLAN INFORMATION FILE

MANAGED CARE PLAN FILE

Data Element Name: APPL-DATE

Definition:

The date on which the managed care organization applied for enrollment into the State’s Medicaid program.

Field Description:

	COBOL PICTURE	Example Value

	9(8)	20090531

Coding Requirements:

Date format is CCYYMMDD (National Data Standard).

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	99999999	Date is Unknown

Error Condition Resulting Error Code

1. Value is Non-Numeric - - 810

2. Value = 99999999 - - 301

3. Value is not a valid date - - 102

4. APPL-DATE < 19650730 535

5. APPL-DATE > DATE-FILE-CREATED [T-MSIS’ Managed Care Header] 535

MANAGED CARE PLAN FILE

Data Element Name: BORDER-STATE-IND

Definition:

A state-defined code indicating the managed care organization as one that provides services or equipment in locations outside of state boundaries.

Field Description:

	COBOL PICTURE	Example Value

	9(1)	"1"

Coding Requirements: Required

	Valid Values	Code Definition
	0	No
	1	Yes
	8	State does not make this distinction
	9	Unknown

Error Condition

Resulting Error Code

1. Value is not in valid values list ???

2. Value is ‘9’ 301

MANAGED CARE PLAN FILE

Data Element Name: BUSINESS-TYPE

Definition:

A code denoting the type of business entity defined in the legal system and/or the managed care entity/plan’s ownership component of the business.

Field Description: Required

	COBOL PICTURE	Example Value

	9(2)	01

Coding Requirements:

Required

Left fill with zeros if number is less than 2 bytes long.

	Valid Values	Code Definition
	01	501(C)(3) NON-PROFIT
	02	FOR-PROFIT, CLOSELY HELD
	03	FOR-PROFIT, PUBLICLY TRADED
	04	OTHER
	99	Unknown

Error Condition Resulting Error Code

1. Value is not numeric 812

2. Value is 99 301

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-ADDR-LN1 THRU MANAGED-CARE-ADDR-LN3

Definition:

The managed care organization’s address listed on the contract with the State.

Field Description:

	COBOL PICTURE	Example Value

	X(28)	"123, Any Lane"

Coding Requirements:

Line 1 is required. Lines2 through 3 can be blank.

Error Condition Resulting Error Code

1. Line 1 value is space-filled 303

2. The text string contains invalid characters ???

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-CITY

Definition:

The city contained in the managed care organization’s address as listed on the contract with the State.

Field Description:

	COBOL PICTURE	Example Value

	X(28)	“Baltimore"

Coding Requirements:

Valid characters in the text string are limited to alpha characters (A-Z, a-z), numbers (0-9), dashes (“-“), commas (“,”), periods (“.”), and spaces.

Error Condition Resulting Error Code

1. Value is space-filled 303

2. The text string contains invalid characters ???

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-EFFECTIVE-DATE

Definition:

The first day that the contract between the state and the managed care entity is in force .

Field Description:

	COBOL PICTURE	Example Value

	9(8)	20090531

Coding Requirements:

Date format is CCYYMMDD

If a complete, valid date is not available fill with 99999999.

	Valid Values	Code Definition
	Valid dates
	99999999	Unknown

Error Condition Resulting Error Code

1. Value is not numeric 810

2. Value is 9-filled 301

3. Value is not a valid date 102

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-EMAIL

Definition:

An email address for CMS to communicate with the health plan, if needed.

Field Description:

	COBOL PICTURE	Example Value

	X(28)	"[email protected]"

Coding Requirements: Required

9-fill If unknown.

Error Condition Resulting Error Code

1. Value is space-filled 303

2. Value is 9-filled 303

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-END-DATE

Definition:

The last day that the contract between the managed care organization and the state is in force.

Field Description:

	COBOL PICTURE	Example Value

	9(8)	20090531

Coding Requirements:

	Date format is CCYYMMDD (National Data Standard). 9-fill if date is unknown.
	If the contractual term is indefinite, enter “end of time” (99991231)
	Enter the last day of the current term if the agreement has a base year and options.

	Valid Values	Code Definition
	Valid dates
	99991231	“End of Time” This value means that the agreement between the managed care entity and the state is still in effect.
	99999999	Unknown

Error Condition Resulting Error Code

1. Value is not numeric 810

2. Value is 9-filled 301

3. Value is not a valid date 102

4. Value is space-filled ???

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-NAME

Definition: The name of the entity under contract with the State Medicaid Agency. The name should be as it appears on the contract.

Field Description:

COBOL Example

PICTURE Value

X(35) “Molina Health Care”

Coding Requirements: Required

Valid characters in the text string are limited to alpha characters (A-Z, a-z), numbers (0-9), dashes (“-“), commas (“,”), periods (“.”), and spaces.

Error Condition Resulting Error Code

1. Value is “SPACE FILLED” 303

2. The text string contains invalid characters ???

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-PLAN-TYPE

Definition: A broad classification of the services that the managed care entity provides .

Field Description:

COBOL Example

PICTURE Value

9(02) 01

Coding Requirements: Required

Left fill with zeros if number is less than 2 bytes long.

Valid Values Code Definition

01 Comprehensive MCO

02 Traditional PCCM Provider

03 Enhanced PCCM Provider

04 HIO

05 Medical-only PIHP (risk or non-risk/non-comprehensive/with inpatient hospital or institutional services)

06 Medical-only PAHP (risk or non-risk/non-comprehensive/no inpatient hospital or institutional services)

07 Long Term Care (LTC) PIHP

08 Mental Health (MH) PIHP

09 Mental Health (MH) PAHP

10 Substance Use Disorders (SUD) PIHP

11 Substance Use Disorders (SUD) PAHP

12 Mental Health (MH) and Substance Use Disorders (SUD) PIHP

31 Mental Health (MH) and Substance Use Disorders (SUD) PAHP

14 Dental PAHP

15 Transportation PAHP

16 Disease Management PAHP

17 PACE

99 Unknown

Error Condition Resulting Error Code

1. Value is not in the valid values list 303

2. Value is 9 filled 301

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-PLAN-POPULATIONS

Definition: The eligibility group or group of individuals that the managed care plan enrolls.

Valid Values Field Description:

<Awaiting the list of eligibility groups from MACPRO.>

Coding Requirements

Please submit all Managed Care Plan Populations using the Managed Care Plan Population Enrolled Record with value 4 as the Managed-Care-Record-Type.

Error Condition Resulting Error Code

1. Value is not in the valid values list 303

2. Value is 9 filled 301

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-RECORD-TYPE

Definition:

The code used to identify a record layout. Each record layout identifies the data elements and their relative positions to one another.

Field Description:

	COBOL PICTURE	Example Value

	X(01)	“1”

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-SERVICE-AREA

Definition:

The area under which the managed care entity is under contract for Medicaid services.

Valid Values Code Definition

Statewide – The managed care entity provides services to Medicaid beneficiaries throughout the entire state.
County – The managed care entity provides services to Medicaid beneficiaries in specified counties.
City – The managed care entity provides services to Medicaid beneficiaries in specified cities.
Region – The managed care entity provides services to Medicaid beneficiaries in specified regions, not defined by individual counties within the State (“region” is State-defined).
Zip Code – The managed care entity program provides services to Medicaid beneficiaries in specified zip codes.
Other – The managed care entity provides services to Medicaid beneficiaries in "other" area(s), not Statewide, County, City, or Region.

Coding Requirements:

Please submit all Managed Care Service Areas using the Managed Care Service Area Record with value 2 as the Managed-Care-Record-Type.

Error Condition Resulting Error Code

1. Value is not in the list of valid values 303

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-SERVICE-AREA-NAME

Definition:

The specific identifiers for the counties, cities, regions, zip codes and/or other geographic areas that the managed care plan serves.

Field Description:

	COBOL PICTURE	Example Value

	X(30)	Four corners region

Coding Requirements: Required

If Managed-care-service-area is 2, 3, 4, 5, or 6 please create/submit a managed-care-service-area-record for each service area.

Put each zip code, city, county, region, or other area descriptor on a separate record.

Use FIPS county codes when service area is defined by counties or cities.

Use 5 digit zip codes when service area definition is zip code based.

When entering other area descriptors, valid characters in the text string are limited to alpha characters (A-Z, a-z), numbers (0-9), dashes (“-“), commas (“,”), periods (“.”) and spaces.

Error Condition Resulting Error Code

1. Value is space-filled 303

2. The text string contains invalid characters ???

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-STATE

Definition:

The managed care organization’s state as listed in the address on the contract with the State. .

Field Description:

	COBOL PICTURE	Example Value

	X9(02)	“24”

Coding Requirements:

Use the two character FIPS state code.

Error Condition Resulting Error Code

1. Value is not in the list of valid values list ???

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-STATE

Definition:

The FIPS state alpha for each U.S. state, Territory, and the District of Columbia.

code of the location where the managed care entity/plan is operating.

Field Description:

COBOL PICTURE	Error Tolerance	Example Value

X(2)	%	"MD"

Coding Requirements:

Must be one of the following FIPS State abbreviations:

AK = Alaska	KY = Kentucky	OH = Ohio
AL = Alabama	LA = Louisiana	OK = Oklahoma
AR = Arkansas	MA = Massachusetts	OR = Oregon
AS = American Samoa	MD = Maryland	PA = Pennsylvania
AZ = Arizona	ME = Maine	PR = Puerto Rico
CA = California	MH = Marshall Islands	PW = Palau
CO = Colorado	MI = Michigan	RI = Rhode Island
CT = Connecticut	MN = Minnesota	SC = South Carolina
DC = Dist of Col	MO = Missouri	SD = South Dakota
DE = Delaware	MP = Northern Mariana Islands	TN = Tennessee
FL = Florida	MS = Mississippi	TX = Texas
FM = Federated States of Micronesia	MT = Montana	UM = U.S. Minor Outlying Islands
GA = Georgia	NC = North Carolina	UT = Utah
GU = Guam/Am Samoa	ND = North Dakota	VA = Virginia
HI = Hawaii	NE = Nebraska	VI = Virgin Islands
IA = Iowa	NH = New Hampshire	VT = Vermont
ID = Idaho	NJ = New Jersey	WA = Washington
IL = Illinois	NM = New Mexico	WI = Wisconsin
IN = Indiana	NV = Nevada	WV = West Virginia
KS = Kansas	NY = New York	WY = Wyoming

Error Condition Resulting Error Code

1.	Value = "99"	301

2.	Value is “Space Filled”	303

3.	Value is 0-filled	304

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-TELEPHONE

An telephone number, including area code, for CMS to communicate with the health plan, if needed.

Field Description:

	COBOL PICTURE	Error Tolerance

	9(10)	4105551234

Coding Requirements:

Enter the digits only (i.e., without parentheses, brackets, dashes, periods, spaces, etc.)

9-fill if unknown

Error Condition Resulting Error Code

1. Value is not in the list of valid values ???

2. Field is 9-filled 301

MANAGED CARE PLAN FILE

Data Element Name: MANAGED-CARE-ZIP-CODE

Definition:

The managed care organization’s zip code as it appears in the address listed on the contract with the State.

Field Description: Required

	COBOL PICTURE	Example Value

	9(9)	21030

Coding Requirements:

Redefined as 9(05) and 9(04)
9(05) is needed If value is unknown fill with 99999
9(04) could be zero filled

Error Condition Resulting Error Code

1. Value is 9-filled 812

MANAGED CARE PLAN FILE

Data Element Name: OPERATING-AUTHORITY

Definition: Fields specifying the type of waivers or demonstrations for which a managed care entity/plan is under contract with.

Field Description:

COBOL Example

PICTURE Value

X(02) “01”

Coding Requirements:

Please fill in the Operating-Authorities that plan is operating under.

Please submit all Operating Authority using the Managed Care Operating Authority Record with value 3 as the Managed-Care-Record-Type.

<Note: This list of valid values will be sync’d with MACPRO’s list when it becomes available.>

Valid Values Code Definition

01 1115 demonstration waiver program –demonstration projects under which most provisions of Section 1902 of the Social Security Act are waived and/or expenditures that would not otherwise be eligible for FFP are authorized. States use these to expand eligibility, restructure Medicaid coverage and secure programmatic flexibility.

02 1915(b)(1) Waiver Program – These waivers permit freedom-of-choice or mandatory managed care with some voluntary managed care.

03 1915(b)(2) – These waivers allow states to use enrollment brokers.

04 1915(b)(3) – These waivers allow states to use savings to provide additional services that are not in the State Plan.

05 1915(b)(4) – These waivers allow fee-for-service selective contracting.

06 1915(c) – These waivers may also be called 2176, Home and Community Based Care, HCBS, HCB, and will often mention specific populations such as MR/DD, aged, disabled/physically disabled, aged/disabled, AIDS/ARC, mental health, TBI/head injury, special care children/technology dependent children.

07 Concurrent 1915(b)/1915(c) waivers – programs, or portions thereof, operating under both 1915(b) managed care and 1915(c) home and community-based services waivers.

08 Concurrent 1915(a)/1915(c) waivers– programs, or portions thereof, operating under both 1915(a) voluntary managed care and 1915(c) home and community-based services waiver

09 Concurrent 1932(a)/1915(c) waivers - programs, or portions thereof, operating under both 1932(a) managed care and 1915(c) home and community-based services waiver.

10 PACE – program that provides pre-paid, capitated comprehensive, health care services to the frail elderly.

11 1905(t) voluntary PCCM program – A PCCM managed care program in which enrollment is voluntary and therefore does not require a waiver.

12 1937benchmark benefit program—programs to provide benefits that differ from Medicaid state plan benefits using managed care and implemented through the State plan.

13 1902(a)(70) Non-emergency medical transportation program –non-emergency medical transportation brokerage programs implemented through the state plan which can vary scope of services, operate on a less-than-statewide basis, and limit freedom of choice

99 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is 9-filled 301

MANAGED CARE PLAN FILE

Data Element Name: PLAN-ID-NUM

Definition: The National health plan identifier assigned to the managed care entity.

Field Description:

COBOL Example

PICTURE Value

X(12) 22323233678A

Coding Requirements:

Please fill in the PLAN-ID-NUM.

Error Condition Resulting Error Code

1. Value is 9-filled 301

MANAGED CARE PLAN FILE

Data Element Name: REIMBURSEMENT-ARRANGEMENT

Definition: A code indicating the how the managed care entity /plan is reimbursed.

Field Description:

COBOL Example

PICTURE Value

X(01) 4

Coding Requirements:

Valid Values Code Definition

SEE ATTACHMENT 1 FOR DEFINITIONS OF TMSIS CODING CATEGORIES

1 Risk-based Capitation, no incentives or risk-sharing

2 Risk-based Capitation with Incentive Arrangements

3 Risk-based Capitation with other risk-sharing Arrangements

4 Non-Risk Capitation

5 Fee-For-Service

6 Primary Care Case Management Payment

7 Other

9 Unknown

Error Condition Resulting Error Code

1. Value is not in list of valid values ???

2. Value is 9-filled 301

MANAGED CARE PLAN FILE

Data Element Name: Core Based Statistical Area (CBSA) Code

Definition:

A code signifying whether the MCO’s service area falls into one or more metropolitan or micropolitan statistical areas.

See the list of metropolitan and micropolitan areas in Appendix ???: OMB CBSA Codes and Descriptions.

Valid Values:

1 = The MCO’s service area falls partially or entirely inside one or more metropolitan areas.

2 = The MCO’s service area falls partially or entirely inside one or more micropolitan areas, but not within any metropolitan areas.

3 = The MCO’s service area falls entirely outside of all metropolitan and micropolitan areas.

Field Description:

	COBOL PICTURE	Example Value

	X(1)	"1"

Coding Requirements:

Whenever a service area straddles two types of areas (e.g, metropolitan & micropolitan, metropolitan & non-CBSA area) classify the service area based on the denser classification .

Error Condition

Resulting Error Code

1. Value is not a valid CBSA code ???

ATTACHMENT 1 – Comprehensive Eligibility Crosswalk

MAS/BOE - INDIVIDUALS COVERED UNDER SEPARATE CHILDREN’S HEALTH INSURANCE PROGRAMS

(S-CHIP)

MSIS Coding (MAS-0, BOE-0)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Children covered under a Title XXI state child health plan (S-CHIP)	42 CFR 457.310, §2110 (b) of the Act.
2	Legal immigrant children and pregnant women covered under a Title XXI state child health plan (S-CHIP).	§2107(e)(1) of the Act, P.L. 111-3.
3	Children receiving dental-only coverage under a state child health plan (S-CHIP)	§2102 and 2110 (b) of the Act, PL 111-3.
4	Targeted low-income pregnant women covered under a Title XXI state child health plan (S-CHIP)	§2112 of the Act, PL 111-3
5	Infants under age 1 born to targeted low-income pregnant women made eligible under a Title XXI state child health plan (S-CHIP).	§2112 of the Act, PL 111-3.
6	Children who have been granted presumptive eligibility under a Title XXI state child health plan (S-CHIP).	42 CFR 457.355, §2105 of the Act.
7	Pregnant women who have been granted presumptive eligibility under a Title XXI state child health plan (S-CHIP).	§2112 of the Act, PL 111-3.
8	Caretaker relatives and children covered under the authority of an 1115 waiver and a Title XXI state child health plan (S-CHIP).	§2107(e) of the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF THE ACT-AGED

MSIS Coding (MAS-1, BOE-1)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Aged individuals receiving SSI, eligible spouses or persons receiving SSI pending a final determination of disposal of resources exceeding SSI dollar limits; and persons considered to be receiving SSI under §1619(b) of the Act.	42 CFR 435.120, §1619(b) of the Act, §1902(a)(10)(A)(I)(II) of the Act, PL 99-643, §2.
2	Aged individuals who meet more restrictive requirements than SSI and who are either receiving or not receiving SSI; or who qualify under §1619 of the Act.	42 CFR 435.121, §1619(b)(3) of the Act, §1902(f) of the Act, PL 99-643, §7.
3	Aged individuals receiving mandatory State supplements.	42 CFR 435.130.
4	Aged individuals who receive a State supplementary payment (but not SSI) based on need.	42 CFR 435.230, §1902(a)(10)(A)(ii) of the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF THE ACT - BLIND/DISABLED

MSIS Coding (MAS-1, BOE-2)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Blind and/or disabled individuals receiving SSI, eligible spouses or persons receiving SSI pending a final determination of blindness, disability, and/or disposal of resources exceeding SSI dollar limits; and persons considered to be receiving SSI under §1619(b) of the Act.	42 CFR 435.120, §1619(b) of the Act, §1902(a)(10)(A)(I)(II) of the Act, PL 99-643, §2.
2	Blind and/or disabled individuals who meet more restrictive requirements than SSI and who are either receiving or not receiving SSI; or who qualify under §1619.	42 CFR 435.121, §1619(b)(3) of the Act, §1902(f) of the Act, PL 99-643, §7.
3	Blind and/or disabled individuals receiving mandatory State supplements.	42 CFR 435.130.
4	Blind and/or disabled individuals who receive a State supplementary payment (but not SSI) based upon need.	42 CFR 435.230, §1902(a)(10)(A)(ii)of the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF THE ACT - CHILDREN

MSIS Coding (MAS-1, BOE-4)

ITEM

DESCRIPTION

CFR/PL CITATIONS

Low Income Families with Children qualified under §1931 of the Act.

42 CFR 435.110,

§1902(a)(10)(A)(I)(I) of the Act,

§1931 of the Act.

Children age 18 who are regularly attending a secondary school or the equivalent of vocational or technical training.

42 CFR 435.110,

§1902(a)(10)(A)(I)(I).

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF THE ACT - ADULTS

MSIS Coding (MAS-1, BOE-5)

ITEM

DESCRIPTION

CFR/PL CITATIONS

Adults deemed essential for well-being of a recipient [see 45 CFR 233.20(a)(2)(vi)] qualified for Medicaid under §1931 of the Act.

42 CFR 435.110,

§1902(a)(10)(A)(I)(I)of the Act,

§1931 of the Act.

Pregnant women who have no other eligible children.
Other adults in "adult only" units.

42 CFR 435.110,

§1902(a)(10)(A)(I)(I)of the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 -U CHILDREN

MSIS Coding (MAS-1, BOE-6) - (OPTIONAL)

ITEM

DESCRIPTION

CFR/PL CITATIONS

Unemployed Parent Program - Cash assistance benefits to low income individuals in two parent families where the principle wage earner is employed fewer than 100 hours a month.

42 CFR 435.110,

§1902(a)(10)(A)(I)(I) of the Act,

§1931 of the Act.

Children age 18 who are regularly attending a secondary school or the equivalent of vocational or technical training.

42 CFR 435.110,

§1902(a)(10)(A)(I)(I) of the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 - U ADULTS

MSIS Coding (MAS-1, BOE-7) - (OPTIONAL)

ITEM

DESCRIPTION

CFR/PL CITATIONS

Adults deemed essential for well-being of a recipient (see 45 CFR 233.20(a)(2)(vi)) qualified under §1931 of the Act (Low Income Families with Children).

42 CFR 435.110,

§1902(a)(10)(A)(I)(I) of the Act,

§1931 of the Act.

Pregnant women who have no other eligible children.
Other Adults in "adult only" units.

42 CFR 435.110,

§1902(a)(10)(A)(I)(I) of the Act.

MAS/BOE - MEDICALLY NEEDY - AGED

MSIS Coding (MAS-2, BOE-1)

ITEM

DESCRIPTION

CFR/PL CITATIONS

Aged individuals who would be ineligible if not enrolled in an HMO. Categorically needy individuals are covered under

42 CFR 435.212, and the same rules apply to medically needy individuals.

42 CFR 435.326.

Aged

42 CFR 435.320,

42 CFR 435.330.

MAS/BOE - MEDICALLY NEEDY - BLIND/DISABLED

MSIS Coding (MAS-2, BOE-2)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Blind and/or disabled individuals who would be ineligible if not enrolled in an HMO. Categorically needy individuals are covered under 42 CFR 435.212 and the same rules apply to medically needy individuals.	42 CFR 435.326.
2	Blind/Disabled	42 CFR 435.322, 42 CFR 435.324, 42 CFR 435.330.
3	Blind and/or disabled individuals who meet all Medicaid requirements except current blindness and/or disability criteria, and have been continuously eligible since 12/73 under the State's requirements.	42 CFR 435.340.

MAS/BOE - MEDICALLY NEEDY - CHILDREN

MSIS Coding (MAS-2, BOE-4)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Individuals under age 18 who, but for income and resources, would be eligible.	§1902(a)(10)(C)(ii)(I) of the Act, PL 97-248, §137.
2	Infants under the age of 1 and who were born after 9/30/84 to and living in the household of medically needy women.	§1902(e)(4) of the Act, PL 98-369, §2362.
3	Other financially eligible individuals under age 18-21, as specified by the State.	42 CFR 435.308.
4	Children who would be ineligible if not enrolled in an HMO. Categorically needy individuals are covered under 42 CFR 435.212 and the same rules apply to medically needy individuals.	42 CFR 435.326.

MAS/BOE - MEDICALLY NEEDY - ADULTS

MSIS Coding (MAS-2, BOE-5)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Pregnant women.	42 CFR 435.301.
2	Caretaker relatives who, but for income and resources, would be eligible.	42 CFR 435.310.
3	Adults who would be ineligible if not enrolled in an HMO. Categorically needy individuals are covered under 42 CFR 435.212 and the same rules apply to medically needy individuals.	42 CFR 435.326.

MAS/BOE - POVERTY RELATED ELIGIBLES - AGED

MSIS Coding (MAS-3, BOE-1)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Qualified Medicare Beneficiaries (QMBs) who are entitled to Medicare Part A, whose income does not exceed 100% of the Federal poverty level, and whose resources do not exceed twice the SSI standard.	§§1902(a)(10)(E)(I) and 1905(p)(1) of the Act, PL 100-203, §4118(p)(8), PL 100-360, §301(a) & (e), PL 100-485, §608(d)(14), PL 100-647, §8434.
2	Specified Low-Income Medicare Beneficiaries (SLMBs) who meet all of the eligibility requirements for QMB status, except for the income in excess of the QMB income limit, but not exceeding 120% of the Federal poverty level.	§4501(b) of OBRA 90, as amended in §1902(a)(10)(E) of the Act.
3	Qualifying individuals having higher income than allowed for QMBs or SLMBs.	§1902(a)(10)(E)(iv) of the Act.
4	Aged individual not described in S 1902(a)(10)(A)(1) of the Act, with income below the poverty level and resources within state limits, who are entitled to full Medicaid benefits.	§1902(a)(10)(A)(ii)(X), 1902(m)(1) of the Act, PL 99-509, §§9402 (a) and (b).

MAS/BOE - POVERTY RELATED ELIGIBLES - BLIND/DISABLED

MSIS Coding (MAS-3, BOE-2)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Qualified Medicare Beneficiaries (QMBs) who are entitled to Medicare Part A, whose income does not exceed 100% of the Federal poverty level, and whose resources do not exceed twice the SSI standard.	§§1902(a)(10)(E)(I) and 1905(p)(1) of the Act, PL 100-203, §4118(p)(8), PL 100-360, §301(a) & (e), PL 100-485, §608(d)(14), PL 100-647, §8434.
2	Specified Low-Income Medicare Beneficiaries (SLMBs) who meet all of the eligibility requirements for QMB status, except for the income in excess of the QMB income limit, but not exceeding 120% of the Federal poverty level.	§4501(b) of OBRA 90 as amended in §1902(a)(10)(E)(I) of the Act.
3	Qualifying individuals having higher income than allowed for QMBs or SLMBs.	§1902(a)(10)(E)(iv) of the Act.
4	Qualified Disabled Working Individuals (QDWIs) who are entitled to Medicare Part A.	§§1902(a)(10)(E)(ii) and 1905(s) of the Act.
5	Disabled individuals not described in §1902(a)(10)(A)(1) of the Act, with income below the poverty level and resources within state limits, which are entitled to full Medicaid benefits.	§§1902(a)(10)(A)(ii)(X), 1902(m)(1) and (3) of the Act, P.L. 99-509, §§9402 (a) and (b).

MAS/BOE - POVERTY RELATED ELIGIBLES - CHILDREN

MSIS Coding (MAS-3, BOE-4)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Infants and children up to age 6 with income at or below 133% of the Federal Poverty Level (FPL).	§§1902(a)(10)(A)(I)(IV) & (VI), 1902(l)(1)(A), (B), & (C) of the Act, PL 100-360, §302(a)(1), PL 100-485, §608(d)(15).
2	Children under age 19 (born after 9/30/83) whose income is at or below 100% of the Federal poverty level within the State's resource requirements.	§1902(a)(10)(A)(I) (VII) of the Act.
3	Infants under age 1 whose family income is below 185% of the poverty level and who are within any optional State resource requirements.	§§1902(a)(10)(A)(ii) (IX) and 1902(l)(1)(D) of the Act, PL 99-509, §§9401(a) & (b), PL 100-203, §4101.
4	Children made eligible under the more liberal income and resource requirements as authorized under §1902(r)(2) of the Act when used to disregard income on a poverty-level-related basis.	§1902(r)(2) of the Act.
5	Children made eligible by a Title XXI Medicaid expansion under the Child Health Insurance Program (CHIP)	P.L. 105-100.

MAS/BOE - POVERTY RELATED ELIGIBLES - ADULTS

MSIS Coding (MAS-3, BOE-5)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Pregnant women with incomes at or below 133% of the Federal Poverty Level.	§1902(a)(10)(A)(I), (IV) and (VI); §1902(l)(1)(A), (B), & (C) of the Act, PL 100-360, §302(a)(1), PL 100-485, §608(d)(15).
2	Women who are eligible until 60 days after their pregnancy, and whose incomes are below 185% of the FPL and have resources within any optional State resource requirements.	§§1902(a)(10)(A)(ii)(IX) and 1902(l)(1)(D) of the Act, PL 99-509, §§9401(a) & (b), PL 100-203, §4101.
3	Caretaker relatives and pregnant women made eligible under more liberal income and resource requirements of §1902(r)(2) of the Act when used to disregard income on a poverty-level related basis.	§1902(r)(2) of the Act.
4	Adults made eligible by a Title XXI Medicaid expansion under the Child Health Insurance Program (CHIP).	Title XXI of the Social Security Act.

MAS/BOE - POVERTY RELATED ELIGIBLES - ADULTS

MSIS Coding (MAS-3, BOE-A)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Women under age 65 who are found to have breast or cervical cancer, or have precancerous conditions.	§1902(a)(10)(a)(ii)(XVIII), P.L. 106-354.

MAS/BOE - OTHER ELIGIBLES - AGED

MSIS Coding (MAS-4, BOE-1)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Aged individuals who meet more restrictive requirements than SSI and who are either receiving or not receiving SSI; or who qualify under §1619 of the Act.	42 CFR 435.121, §1619(b)(3) of the Act, §1902(f) of the Act, PL 99-643, §7.
2	Aged individuals who are ineligible for optional State supplements or SSI due to requirements that do not apply under title XIX.	42 CFR 435.122.
3	Aged essential spouses considered continuously eligible since 12/73; and some spouses who share hospital or nursing facility rooms for 6 months or more.	42 CFR 435.131.
4	Institutionalized aged individuals who have been continuously eligible since 12/73 as inpatients or residents of Title XIX facilities.	42 CFR 435.132.
5	Aged individuals who would be SSI/SSP eligible except for the 8/72 increase in OASDI benefits.	42 CFR 435.134.
6	Aged individuals who would be eligible for SSI but for title II cost-of-living adjustment(s).	42 CFR 435.135.
7	Aged aliens who are not lawful, permanent residents or who do not have PRUCOL status, but who are otherwise qualified, and who require emergency care.	PL 99-509, §9406.
8	Aged individuals who would be eligible for AFDC, SSI, or an optional State supplement if not in a medical institution.	42.CFR 435.211, §1902(a)(10)(A)(ii) and §1905(a) of the Act.
9	Aged individuals who meet income and resource requirements for AFDC, SSI, or an optional State supplement.	42 CFR 435.210, §1902(a)(10)(A)(ii) and §1905 of the Act.
10	Aged individuals who have become ineligible and who are enrolled in a qualified HMO or "§1903(m)(2)(G) entity" that has a risk contract.	42 CFR 435.212 §1902(e)(2), PL 99-272, §9517, PL 100-203, §4113(d).
11	Aged individuals who, solely because of coverage under a home and community based waiver, are not in a medical institution, but who would be eligible if they were.	42 CFR 435.217, §1902(a)(10)(A)(ii), (VI); 50 PL 100-13.
12	Aged individuals who elect to receive hospice care who would be eligible if in a medical institution.	§1902(a)(10)(A)(ii), (VII) of the Act, PL 99-272, §9505.
13	Aged individuals in institutions who are eligible under a special income level specified in Supplement 1 to Attachment 2.6-A of the State's title XIX Plan.	42 CFR 435.236, §1902(a)(10)(A)(ii) of the Act.

MAS/BOE - OTHER ELIGIBLES - BLIND/DISABLED

MSIS Coding (MAS-4, BOE-2)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Blind and/or disabled individuals who meet more restrictive requirements than SSI, including both those receiving and not receiving SSI payments	42 CFR 435.121, §1619(b)(3) of the Act, §1902(f) of the Act, PL 99-643, §7.
2	Blind and/or disabled individuals who are ineligible for optional State supplements or SSI due to requirements that do not apply under title XIX.	42 CFR 435.122.
3	Blind and/or disabled essential spouses considered continuously eligible since 12/73; and some spouses who share hospital or nursing facility rooms for 6 months or more.	42 CFR 435.131.
4	Institutionalized blind and/or disabled individuals who have been continuously eligible since 12/73 as inpatients or residents of Title XIX facilities.	42 CFR 435.132.
5	Blind and/or disabled individuals who would be SSI/SSP, eligible except for the 8/72 increase in OASDI benefits.	42 CFR 435.134.
6	Blind and/or disabled individuals who would be eligible for SSI but for title II cost-of-living adjustment(s).	42 CFR 435.135, §503 PL 94-566.
7	Blind and/or disabled aliens who are not lawful, permanent residents or who do not have PRUCOL status, but who are otherwise qualified, and who require emergency care.	PL 99-509, §9406.
8	Blind and/or disabled individuals who meet all Medicaid requirements except current blindness, or disability criteria, who have been continuously eligible since 12/73 under the State's 12/73 requirements.	42 CFR 435.133.
9	Blind and/or disabled individuals, age 18 or older, who became blind or disabled before age 22 and who lost SSI or State supplementary payments eligibility because of an increase in their OASDI (childhood disability) benefits.	§1634(c) of the Act; PL 99-643, §6.
10	Blind and/or disabled individuals who would be eligible for AFDC, SSI, or an optional State supplement if not in a medical institution.	42 CFR 435.211, §§1902(a)(10)(A)(ii) and 1905(a) of the Act.
11	Qualified severely impaired blind or disabled individuals under age 65, who, except for earnings, are eligible for SSI.	§§1902(a)(10)(A)(I)(II) and 1905(q) of the Act, PL 99-509, §9404 and §1619(b)(8) of the Act, PL 99-643, §7
12	Blind and/or disabled individuals who meet income and resource requirements for AFDC, SSI, or an optional State supplement.	42 CFR 435.210, §§1902(a)(10)(A)(ii) and 1905 of the Act.
13	Working disabled individuals who buy-in to Medicaid	§1902(a)(10)(A)(ii)(XIII).
14	Blind and/or disabled individuals who have become ineligible who are enrolled in a qualified HMO or "§1903(m)(2)(G) entity" that has a risk contract.	42 CFR 435.212 §1902(e)(2) of the Act; PL 99-272, §9517; PL 100-203, §4113(d).
15	Blind and/or disabled individuals who, solely because of coverage under a home and community based waiver, are not in a medical institution and who would be eligible if they were.	42 CFR 435.217, §1902(a)(10)(A)(ii)(VI) of the Act, 50 PL 100-13.
16	Blind and/or disabled individuals who elect to receive hospice care, and who would be eligible if in a medical institution.	§1902(a)(10)(A)(ii)(VII), PL 99-272, §9505
17	Blind and/or disabled individuals in institutions who are eligible under a special income level specified in Supplement 1 to Attachment 2.6-A of the State's title XIX Plan.	42 CFR 435.231. §1902(a)(10)(A)(ii) of the Act.
18	Blind and/or disabled widows and widowers who have lost SSI/SSP benefits but are considered eligible for Medicaid until they become entitled to Medicare Part A.	§1634 of the Act, PL 101-508, §5103.
19	Certain Disabled children, 18 or under, who live at home, but who, if in a medical institution, would be eligible for SSI or a State supplemental payment.	42 CFR 435.225; §1902(e)(3) of the Act.
20	Continuation of Medicaid eligibility for disabled children who lose SSI benefits because of changes in the definition of disability.	§1902(a)(10)(A)(ii) of the Act; P.L. 15-32, §491.
21	Disabled individuals with medically improved disabilities made eligible under the Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999.	§1902(a)(10)(A)(ii)(XV) of the Act.

MAS/BOE - OTHER ELIGIBLES - CHILDREN

MSIS Coding (MAS-4, BOE-4)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Children of families receiving up to 12 months of extended Medicaid benefits (for those eligible after 4/1/90).	§1925 of the Act, PL 100-485, §303.
2	"Qualified children" under age 19 born after 9/30/83 or at an earlier date at State option, who meet the State's AFDC income and resource requirements.	§§1902(a)(10)(A)(I)(III) and 1905(n) of the Act, PL 98-369, §2361, PL 99-272, §9511, PL 100-203, §4101.
3	Children of individuals who are ineligible for AFDC-related Medicaid because of requirements that do not apply under title XIX.	42 CFR 435.113.
4	Children of individuals who would be eligible for Medicaid under §1931 of the Act (Low income families with children) except for the 7/1/72 (PL 92-325) OASDI increase and were entitled to OASDI and received cash assistance in 8/72.	42 CFR 435.114.
5	Children whose mothers were eligible for Medicaid at the time of childbirth, and are deemed eligible for one year from birth as long as the mother remained eligible, or would have if pregnant, and the child remains in the same household as the mother.	42 CFR 435.117, §1902(e)(4) of the Act, PL 98-369, §2362.

6	Children of aliens who are not lawful, permanent residents or who do not have PRUCOL status, but who are otherwise qualified, and who require emergency care.	PL 99-509, §9406.
7	Children who meet income and resource requirements for AFDC, SSI, or an optional State supplement	42 CFR 435.210, §1902(a)(10)(A)(ii) and §1905 of the Act.
8	Children who would be eligible for AFDC, SSI, or an optional State supplement if not in a medical institution.	42 CFR 435.211, §1902(a)(10)(A)(ii) and §1905(a) of the Act.
9	Children who have become ineligible who are enrolled in a qualified HMO or "§1903(m)(2)(G) entity" that has a risk contract.	42 CFR 435.212, §1902(e)(2) of the Act, PL 99-272, §9517, PL 100-203, §4113(d).
10	Children of individuals who elect to receive hospice care, and who would be eligible if in a medical institution.	§1902(a)(10)(A)(ii)(VII), PL 99-272, §9505.
11	Children who would be eligible for AFDC if work-related child care costs were paid from earnings rather than received as a State service.	42 CFR 435.220.
12	Children of individuals who would be eligible for AFDC if the State used the broadest allowable AFDC criteria.	42 CFR 435.223, §§1902(a)(10)(A)(ii) and 1905(a) of the Act.
13	Children who solely because of coverage under a home and community based waiver, are not in a medical institution, but who would be eligible if they were.	42 CFR 435.217, §1902(a)(10)(A)(ii)(VI) of the Act.
14	Children not described in §1902(a)(10)(A)(I) of the Act, "Ribikoff Kids", who meet AFDC income and resource requirements, and are under a State-established age (18-21).	§§1902(a)(10)(A)(ii) and 1905(a)(I) of the Act, PL 97-248, §137.

MAS/BOE - OTHER ELIGIBLES - ADULTS

MSIS Coding (MAS-4, BOE-5)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Families receiving up to 12 months of extended Medicaid benefits (if eligible on or after 4/1/90).	§1925 of the Act, PL 100-485, §303.
2	Qualified pregnant women whose pregnancies have been medically verified and who meet the State's AFDC income and resource requirements.	§§1902(a)(10)(A)(I)(III) and 1905(n) of the Act, PL 98-369, §2361, PL 99-272, §9511, PL 100-203 §4101.
3	Adults who are ineligible for AFDC-related Medicaid because of requirements that do not apply under title XIX.	42 CFR 435.113.
4	Adults who would be eligible for Medicaid under §1931 of the Act (Low income families with children) except for the 7/1/72 (PL 92-325) OASDI increase; and were entitled to OASDI and received cash assistance in 8/72.	42 CFR 435.114.
5	Women who were eligible while pregnant, and are eligible for family planning and pregnancy related services until the end of the month in which the 60th day occurs after the pregnancy	§1902(e)(5) of the Act, PL 98-369, PL 100-203, §4101, PL 100-360, §302(e).
6	Adult aliens who are not lawful, permanent residents or who do not have PRUCOL status, but who are otherwise qualified, and who require emergency care.	PL 99-509, §9406.
7	Adults who meet the income and resource requirements for AFDC, SSI, or an optional State Supplement.	42 CFR 435.210, §§1902(a)(10)(A)(ii) and 1905 of the Act.
8	Adults who would be eligible for AFDC, SSI, or an optional State Supplement if not in a medical institution.	42 CFR 435.211, §§1902(a)(10)(A)(ii) and 1905(a) of the Act.
9	Adults who have become ineligible who are enrolled in a qualified HMO or "§1903(m)(2)(G) entity" that has a risk contract.	42 CFR 435.212, §1902(e)(2)(A) of the Act, PL 99-272, §9517, PL 100-203, §4113(d).
10	Adults who solely because of coverage under a home and community based waiver, are not in a medical institution, but who would be eligible if they were.	42 CFR 435.217, §1902(a)(10)(A)(ii)(VI) of the Act.
11	Adults who elect to receive hospice care, and who would be eligible if in a medical institution.	§1902(a)(10)(A)(ii), (VII); PL 99-272, §9505.
12	Adults who would be eligible for AFDC if work-related child care costs were paid from earnings rather than received as a State service.	42 CFR 435.220.
13	Pregnant women who have been granted presumptive eligibility.	§§1902(a)(47) and 1920 of the Act, PL 99-509, §9407.
14	Adults who would be eligible for AFDC if the State used the broadest allowable AFDC criteria.	42 CFR 435.223, §§1902(a)(10)(A)(ii) and 1905(a) of the Act.

MAS/BOE - OTHER ELIGIBLES - FOSTER CARE CHILDREN

MSIS Coding (MAS-4, BOE-8)

ITEM	DESCRIPTION	CFR/PL CITATIONS
1	Children for whom the State makes adoption assistance or foster care maintenance payments under Title IV-E.	42 CFR 435.145, §1902(a)(10)(A)(i)(I) of the Act.
2	Children with special needs covered by State foster care payments or under a State adoption assistance agreement which does not involve Title IV-E.	§1902(a)(10)(A)(ii) (VIII) of the Act, PL 99-272, §9529.
3	Children leave foster care due to age.	Foster Care Independence Act of 1999.

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION

MSIS Coding (MAS-5, BOE-1)

ITEM

DESCRIPTION

CFR/PL CITATION

Aged individuals made eligible under the authority of a §1115 waiver due to poverty-level related eligibility expansions.

§1115(a)(1), (a)(2) & (b)(1) of the Act,

§1902(a)(10), and

§1903(m) of the Act.

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION

MSIS Coding (MAS-5, BOE-2)

ITEM

DESCRIPTION

CFR/PL CITATION

Blind and/or disabled individuals made eligible under the authority of a §1115 waiver due to poverty-level-related eligibility

§1115(a)(1), (a)(2) & (b)(1) of the Act,

§1902(a)(10), and

§1903(m) of the Act.

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION

MSIS Coding (MAS-5, BOE-4)

ITEM

DESCRIPTION

CFR/PL CITATION

Children made eligible under the authority of a §1115 waiver due to poverty-level-related eligibility expansions.

§1115(a)(1), (a)(2) & (b)(1) of the Act,

§1902(a)(10), and §1903(m) of the Act.

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION

MSIS Coding (MAS-5, BOE-5)

ITEM

DESCRIPTION

CFR/PL CITATION

Caretaker relatives, pregnant women and/or adults without dependent children made eligible under the authority of at §1115 waiver due to poverty-level-related eligibility expansions.

§1115(a)(1) and (a)(2) of the Act,

§1902(a)(10), §1903(m).

ATTACHMENT 2 - Types of Service Reference

DEFINITIONS OF TYPES OF SERVICE

The following definitions are adaptations of those given in the Code of Federal Regulations. These definitions, although abbreviated, are intended to facilitate the classification of medical care and services for reporting purposes. They do not modify any requirements of the Act or supersede in any way the definitions included in the Code of Federal Regulations (CFR).

Effective FY 1999, services provided under Family Planning, EPSDT, Rural Health Clinics, FQHC’s, and Home-and-Community-Based Waiver programs will be coded according to the types of services listed below. Specific programs with which these services are associated will be identified using the program type coding as defined in Attachment 5.

1. Unduplicated Total.--Report the unduplicated total of recipients by maintenance assistance status (MAS) and by basis of eligibility (BOE). A recipient receiving more than one type of service is reported only once in the unduplicated total.

2. Inpatient Hospital Services (MSIS Code=01)(See 42 CFR 440.10).--These are services that are:

o Ordinarily furnished in a hospital for the care and treatment of inpatients;

o Furnished under the direction of a physician or dentist (except in the case of nurse‑midwife services per 42 CFR 440.165); and

o Furnished in an institution that:

- Is maintained primarily for the care and treatment of patients with disorders other than mental diseases;

- Is licensed or formally approved as a hospital by an officially designated authority for State standard setting;

- Meets the requirements for participation in Medicare (except in the case of medical supervision of nurse‑midwife services per 42 CFR 440.165); and

- Has in effect a utilization review plan applicable to all Medicaid patients that meets the requirements in 42 CFR 482.30 unless a waiver has been granted by the Secretary of Health and Human Services.

Inpatient hospital services do not include nursing facility services furnished by a hospital with swing‑bed approval. However, include services provided in a psychiatric wing of a general hospital if the psychiatric wing is not administratively separated from the general hospital.

3. Mental Health Facility Services (See 42 CFR 440.140, 440.160, and 435.1009).--An institution for mental diseases is a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis, treatment or care of individuals with mental diseases, including medical care, nursing care, and related services. Report totals for services defined under 3a and 3b.

3a. Inpatient Psychiatric Facility Services for Individuals Age 21 and Under (MSIS Code=04)(See 42 CFR 440.160 and 441.150(ff)). --These are services that:

o Are provided under the direction of a physician;

o Are provided in a psychiatric facility or inpatient program accredited by the Joint Commission on the Accreditation of Hospitals; and,

o Meet the requirements set forth in 42 CFR Part 441, Subpart D (inpatient psychiatric services for individuals age 21 and under in psychiatric facilities or programs).

3b. Other Mental Health Facility Services (Individuals Age 65 or Older) (MSIS Code=02)(See 42 CFR 440.140(a) and Part 441, Subpart C).--These are services provided under the direction of a physician for the care and treatment of recipients in an institution for mental diseases that meets the requirements specified in 42 CFR 440.140(a).

4. Nursing Facilities (NF) Services(MSIS Code=07)(See 42 CFR 440.40 and 440.155).--These are services provided in an institution (or a distinct part of an institution) which:

o Is primarily engaged in providing to residents:

- Skilled nursing care and related services for residents who require medical or nursing care;

- Rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or

- On a regular basis, health-related care and services to individuals who, because of their mental or physical condition, require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; and;

o Meet the requirements for a nursing facility described in subsections 1919(b), (c), and (d) of the Act regarding:

- Requirements relating to provision of services;

- Requirements relating to residents’ rights; and

- Requirements relating to administration and other matters.

NOTE: ICF Services - All Other.--This is combined with nursing facility services.

5. ICF Services for the Mentally Retarded(MSIS Code=05) (See 42 CFR 440.150 and Part 483 of Subpart I).--These are services provided in an institution for mentally retarded persons or persons with related conditions if the:

o Primary purpose of the institution is to provide health or rehabilitative services to such individuals;

o Institution meets the requirements in 42 CFR 442, Subpart C (certification of ICF/MR); and

o The mentally retarded recipients for whom payment is requested are receiving active treatment as defined in 42 CFR 483.440(a).

Physicians' Services (MSIS Code=08)(See 42 CFR 440.50).--Whether furnished in a physician's office, a recipient's

home, a hospital, a NF, or elsewhere, these are services provided:

o Within the scope of practice of medicine or osteopathy as defined by State law; and

o By, or under, the personal supervision of an individual licensed under State law to practice medicine or osteopathy, or dental medicine or dental surgery if State law allows such services to be provided by either a physician or dentist.

7. Outpatient Hospital Services (MSIS Code=11)(See 42 CFR 440.20).--These are preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished:

o To outpatients;

o Except in the case of nurse-midwife services (see 42 CFR 440.165), under the direction of a physician or dentist; and

o By an institution that:

- Is licensed or formally approved as a hospital by an officially designated authority for State standard setting; and

- Except in the case of medical supervision of nurse midwife services (see 42 CFR 440.165), meets the requirements for participation in Medicare as a hospital.

8. Prescribed Drugs (MSIS Code=16)(See 42 CFR 440.120(a)).--These are simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance that are:

o Prescribed by a physician or other licensed practitioner within the scope of professional practice as defined and limited by Federal and State law;

o Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and

o Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's records.

9. Dental Services (MSIS Code=09)(See 42 CFR 440.100 and 42 CFR 440.120 (b)).--These are diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession, including treatment of:

o The teeth and associated structures of the oral cavity; and

o Disease, injury, or an impairment that may affect the oral or general health of the recipient.

A dentist is an individual licensed to practice dentistry or dental surgery. Dental services include dental screening and dental clinic services.

NOTE: Include services related to providing and fitting dentures as dental services. Dentures mean artificial structures made by, or under the direction of, a dentist to replace a full or partial set of teeth.

Dental services do not include services provided as part of inpatient hospital, outpatient hospital, non-dental clinic, or laboratory services and billed by the hospital, non‑dental clinic, or laboratory or services which meet the requirements of 42 CFR 440.50(b) (i.e., are provided by a dentist but may be provided by either a dentist or physician under State law).

10. Other Licensed Practitioners' Services (MSIS Code=10)(See 42 CFR 440.60).--These are medical or remedial care or services, other than physician services or services of a dentist, provided by licensed practitioners within the scope of practice as defined under State law. The category “Other Licensed Practitioners' Services” is different than the “Other Care” category. Examples of other practitioners (if covered under State law) are:

o Chiropractors;

o Podiatrists;

o Psychologists; and

o Optometrists.

Other Licensed Practitioners' Services include hearing aids and eyeglasses only if they are billed directly by the professional practitioner. If billed by a physician, they are reported as Physicians' Services. Otherwise, report them under Other Care.

Other Licensed Practitioners' Services do not include prosthetic devices billed by physicians, laboratory or X-ray services provided by other practitioners, or services of other practitioners that are included in inpatient or outpatient hospital bills. These services are counted under the related type of service as appropriate. Devices billed by providers not included under the listed types of service are counted under Other Care.

Report Other Licensed Practitioners' Services that are billed by a hospital as inpatient or outpatient services, as appropriate.

Speech therapists, audiologists, opticians, physical therapists, and occupational therapists are not included within Other Licensed Practitioners' Services.

Chiropractors' services include only services that are provided by a chiropractor (who is licensed by the State) and consist of treatment by means of manual manipulation of the spine that the chiropractor is legally authorized by the State to perform.

11. Clinic Services (MSIS Code=12)(See 42 CFR 440.90).--Clinic services include preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that are provided:

o To outpatients;

o By a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients including services furnished outside the clinic by clinic personnel to individuals without a fixed home or mailing address. For reporting purposes, consider a group of physicians who share, only for mutual convenience, space, services of support staff, etc., as physicians, rather than a clinic, even though they practice under the name of the clinic; and

o Except in the case of nurse-midwife services (see 42 CFR 440.165), are furnished by, or under, the direction of a physician.

NOTE: Place dental clinic services under dental services. Report any services not included above under other care. A clinic staff may include practitioners with different specialties.

12. Laboratory and X‑Ray Services(MSIS Code=15)(See 42 CFR 440.30).--These are professional or technical laboratory and radiological services that are:

o Ordered and provided by or under the direction of a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by State law or ordered and billed by a physician but provided by referral laboratory;

o Provided in an office or similar facility other than a hospital inpatient or outpatient department or clinic; and

o Provided by a laboratory that meets the requirements for participation in Medicare.

X-ray services provided by dentists are reported under dental services.

13. Sterilizations (MSIS Code=24)(See 42 CFR 441, Subpart F).--These are medical procedures, treatment or operations for the purpose of rendering an individual permanently incapable of reproducing.

14. Home Health Services (MSIS Code=13) (See 42 CFR 440.70).--These are services provided at the patient's place of residence, in compliance with a physician's written plan of care that is reviewed every 62 days. The following items and services are mandatory.

o Nursing services, as defined in the State Nurse Practice Act, that is provided on a part‑time or intermittent basis by a home health agency (a public or private agency or organization, or part of any agency or organization, that meets the requirements for participation in Medicare). If there is no agency in the area, a registered nurse who:

- Is licensed to practice in the State;

- Receives written orders from the patient's physician;

- Documents the care and services provided; and

- Has had orientation to acceptable clinical and administrative record keeping from a health department nurse;

o Home health aide services provided by a home health agency; and

o Medical supplies, equipment, and appliances suitable for use in the home.

The following therapy services are optional: physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or by a facility licensed by the State to provide these medical rehabilitation services. (See 42 CFR 441.15.)

Place of residence is normally interpreted to mean the patient's home and does not apply to hospitals or NFs. Services received in a NF that are different from those normally provided as part of the institution's care may qualify as home health services. For example, a registered nurse may provide short‑term care for a recipient in a NF during an acute illness to avoid the recipient's transfer to another NF.

15. Personal Support Services.--Report total unduplicated recipients and payments for services defined in 15a through 15i.

15a. Personal Care Services (MSIS Code=30)(See 42 CFR 440.167).--These are services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease that are:

o Authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the State) otherwise authorized for the individual in accordance with a service plan approved by the State; and

o Provided by an individual who is qualified to provide such services and who is not a member of the individual’s family.

15b. Targeted Case Management Services (MSIS Code=31)(See §1915(g)(2) of the Act).--These are services that are furnished to individuals eligible under the plan to gain access to needed medical, social, educational, and other services. The agency may make available case management services to:

o Specific geographic areas within a State, without regard to statewide requirement in 42 CFR 431.50; and

o Specific groups of individuals eligible for Medicaid, without regard to the comparability requirements in 42 CFR 440.240.

The agency must permit individuals to freely choose any qualified Medicaid provider except when obtaining case management services in accordance with 42 CFR 431.51.

15c. Rehabilitative Services (MSIS Code=33)(See 42 CFR 440.130(d)).--These include any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts within the scope of his/her practice under State law for maximum reduction of physical or mental disability and restoration of a recipient to his/her best possible functional level.

15d. Physical Therapy, Occupational Therapy, and Services For Individuals With Speech, Hearing, and Language Disorders (MSIS Code=34)(See 42 CFR 440.110).--These are services prescribed by a physician or other licensed practitioner within the scope of his or her practice under State law and provided to a recipient by, or under the direction of, a qualified physical therapist, occupational therapist, speech pathologist, or audiologist. It includes any necessary supplies and equipment.

15e. Hospice Services (MSIS Code=35)(See 42 CFR 418.202).--Whether received in a hospice facility or elsewhere, these are services that are:

o Furnished to a terminally ill individual, as defined in 42 CFR 418.3;

o Furnished by a hospice, as defined in 42 CFR 418.3, that meets the requirements for participation in Medicare specified in 42 CFR 418, Subpart C or by others under an arrangement made by a hospice program that meets those requirements and is a participating Medicaid provider; and

o Furnished under a written plan that is established and periodically reviewed by:

The attending physician;

The medical director or physician designee of the program, as described in 42 CFR 418.54; and

- The interdisciplinary group described in 42 CFR 418.68.

15f. Nurse Midwife (MSIS Code=36)(See 42 CFR 440.165 and 441.21).--These are services that are concerned with management and the care of mothers and newborns throughout the maternity cycle and are furnished within the scope of practice authorized by State law or regulation.

15g. Nurse Practitioner (MSIS Code=37)(See 42 CFR 440.166 and 441.22).--These are services furnished by a registered professional nurse who meets State’s advanced educational and clinical practice requirements, if any, beyond the 2 to 4 years of basic nursing education required of all registered nurses.

15h. Private Duty Nursing (MSIS Code=38)(See 42 CFR 440.80).--When covered in the State plan, these are services of registered nurses or licensed practical nurses provided under direction of a physician to recipients in their own homes, hospitals or nursing facilities (as specified by the State).

15i. Religious Non-Medical Health Care Institutions (MSIS Code=39)(See 42 CFR 440.170(b)(c)).--These are non-medical health care services equivalent to a hospital or extended care level of care provided in facilities that meet the requirements of Section 1861(ss)(1) of the Act.

16. Other Care (See 42 CFR 440.120(b), (c), and (d), and 440.170(a)).--Report total unduplicated recipients and payments for services in sections 16a, 16b, and 16c. Such services do not meet the definition of, and are not classified under, any of the previously described categories.

16a. Transportation (MSIS Code=26)(See 42 CFR 440.170(a)).--Report totals for services provided under this title to include transportation and other related travel services determined necessary by you to secure medical examinations and treatment for a recipient.

NOTE: Transportation, as defined above, is furnished only by a provider to whom a direct vendor payment can appropriately be made. If other arrangements are made to assure transportation under 42 CFR 431.53, FFP is available as an administrative cost.

16b. Abortions (MSIS Code=25)(See 42 CFR 441, Subpart E).--In accordance with the terms of the DHHS Appropriations Bill and 42 CFR 441, Subpart E, FFP is available for abortions:

o When a physician has certified in writing to the Medicaid agency that, on the basis of his or her professional judgment, the life of the mother would be endangered if the fetus were carried to term; or

o When the abortion is performed to terminate a pregnancy resulting from an act of rape of incest. FFP is not available for an abortion under any other circumstances.

16c. Other Services (MSIS Code=19).--These services do not meet the definitions of any of the previously described service categories. They may include, but are not limited to:

o Prosthetic devices (see 42 CFR 440.120(c)) which are replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as defined by State law to:

- Artificially replace a missing portion of the body;

- Prevent or correct physical deformity or malfunctions; or

- Support a weak or deformed portion of the body.

o Eyeglasses (see 42 CFR 440.120 (d)). Eyeglasses mean lenses, including frames, and other aids to vision prescribed by a physician skilled in diseases of the eye or an optician. It includes optician fees for services.

o Home and Community‑Based Waiver services (See §1915(c) of the Act and 42 CFR 440.180) that cannot be associated with other TYPE-OF-SERVICE codes (e.g., community homes for the disabled and adult day care.)

17. Capitated Care (See 42 CFR Part 434).--This includes enrollees and capitated payments for the plan types defined in 17 a and b below. Report unduplicated enrolled eligibles and payments for 17 a and b.

17a. Health Maintenance Organization (HMO) and Health Insuring Organization (HIO) (MSIS Code=20).--These include plans contracted to provide capitated comprehensive services. An HMO is a public or private organization that contracts on a prepaid capitated risk basis to provide a comprehensive set of services and is federally qualified or State-plan defined. An HIO is an entity that provides for or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

17b. Prepaid Health Plans (PHP) (MSIS Code=21).--These include plans that are contracted to provide less than comprehensive services. Under a non-risk or risk arrangement, the State may contract with (but not limited to these entities) a physician, physician group, or clinic for a limited range of services under capitation. A PHP is an entity that provides a non-comprehensive set of services on either capitated risk or non-risk basis or the entity provides comprehensive services on a non-risk basis.

NOTE: Include dental, mental health, and other plans covering limited services under PHP.

18. Primary Care Case Management (PCCM) (MSIS Code=22)(See §1915(b)(1) of the Act).--The State contracts directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary care physician a monthly case management fee. Report these recipients and associated PCCM fees in this section.

NOTE: Where the fee includes services beyond case management, report the enrollees and fees under prepaid health plans (17b).

SERVICE HIERARCHY

Experience has demonstrated there can be instances when more than one service area category could be applicable for a provided service. The following rules apply to these instances:

o The specific service categories of sterilizations and abortions take precedence over provider categories, such as inpatient hospital or outpatient hospital.

o Services of a physician employed by a clinic are reported under clinic services if the clinic is the billing entity. X-rays processed by the clinic in the course of treatment, however, are reported under X-ray services.

o Services of a registered nurse attending a resident in a NF are reported (if they qualified under the coverage rules) under home health services if they were not billed as part of the NF bill.

ATTACHMENT 3 - Program Type Reference

DEFINITIONS OF PROGRAM TYPES

The following definitions describe special Medicaid programs that are coded independently of type of service for MSIS purposes. These programs tend to cover bands of services that cut across many types of service.

Program Type 1. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) (See 42 CFR 440.40(b)).--This includes either general health screening services and vision, dental, and hearing services furnished to Medicaid eligibles under age 21 to fulfill the requirements of the EPSDT program or services rendered based on referrals from EPSDT visits. The Act specifies two sets of EPSDT screenings:

o Periodic screenings, which are provided at distinct intervals determined by the State, and which must include the following services:

- A comprehensive health and developmental history assessment (including assessment of both physical and mental health development);

- A comprehensive unclothed physical exam;

- Appropriate immunizations according to the Advisory Committee on Immunization Practices schedule;

- Laboratory tests (including blood lead level assessment); and

- Health education (including anticipatory guidance); and

o Interperiodic screenings, which are provided when medically necessary to determine the existence of suspected physical or mental illness or conditions.

Program Type 2. Family Planning (See 42 CFR 440.40(c)).-- Only items and procedures clearly provided or performed for family planning purposes and matched at the 90 percent FFP rate should be included as Family Planning. Services covered under this program include, but are not limited to:

o Counseling and patient education and treatment furnished by medical professionals in accordance with State law;

o Laboratory and X-ray services;

o Medically approved methods, procedures, pharmaceutical supplies, and devices to prevent conception;

o Natural family planning methods; and

o Diagnosis and treatment for infertility.

NOTE: CMS’s Revised Financial Management Review Guide for Family Planning Services describes items and procedures eligible for the enhanced match as family planning services.

Program Type 3. Rural Health Clinics (RHC)(See 42 CFR 440.20(b)).--These include services (as allowed by State law) furnished by a rural health clinic which has been certified in accordance with the conditions of 42 CFR Part 491 (certification of certain health facilities). Services performed in RHCs include, but are not limited to:

o Services furnished by a physician within the scope of his or her profession as defined by State law. The physician performs these services in or away from the clinic and has an agreement with the clinic providing that he or she will be paid for these services;

o Services furnished by a physician assistant, nurse practitioner, nurse midwife, or other specialized nurse practitioner (as defined in 42 CFR 405.2401 and 491.2) if the services are furnished in accordance with the requirements specified in 42 CFR 405.2412(a);

o Services and supplies provided in conjunction with professional services furnished by a physician, physician assistant, nurse practitioner, nurse midwife, or specialized nurse practitioner. (See 42 CFR 405.2413 and 405.2415 for the criteria determining whether services and supplies are included here.); or

o Part‑time or intermittent visiting nurse care and related medical supplies (other than drugs and biologicals) if:

- The clinic is located in an area in which the Secretary has determined that there is a shortage of home health agencies (see 42 CFR 405.2417);

- The services are furnished by a registered nurse or licensed practical or vocational nurse employed, or otherwise compensated for the services, by the clinic;

- The services are furnished under a written plan of treatment that is either established and reviewed at least every 60 days by a supervising physician of the clinic, or that is established by a physician, physician's assistant, nurse practitioner, nurse midwife, or specialized nurse practitioner and reviewed and approved at least every 60 days by a supervising physician of the clinic; and

- The services are furnished to a homebound patient. For purposes of visiting nurse services, a homebound recipient means one who is permanently or temporarily confined to a place of residence because of a medical or health condition and leaves the place of residence infrequently. For this purpose, a place of residence does not include a hospital or nursing facility.

Program Type 4. Federally Qualified Health Center (FQHC) (See §1905(a)(2) of the Act).--FQHCs are facilities or programs more commonly known as community health centers, migrant health centers, and health care for the homeless programs. A facility or program qualifies as a FQHC providing services covered under Medicaid if:

o They receive grants under §§329, 330, or 340 of the Public Health Service Act (PHS);

o The Health Resources and Services Administration, PHS, certifies the center as meeting FQHC requirements; or

o The Secretary determines that the center qualifies through waiver of the requirements.

Services performed in FHQCs are defined the same as the services provided by rural health clinics. They may include physician services, services provided by physician assistants, nurse practitioners, clinical psychologists, clinical social workers, and services and supplies incident to such services as are otherwise covered if furnished by a physician or as incident to a physician's services. In certain cases, services to a homebound Medicaid patient may be provided. Any other ambulatory service included in the State's Medicaid plan is considered covered by a FQHC program if the center offers it.

Program Type 5. Indian Health Services (See §1911 of the Act) (See 42 CFR 431.110).--These are services provided by the Indian Health Services (IHS), an agency charged with providing the primary source of health care for American Indian and Alaska Native people who are members of federally recognized tribes and organizations. A State plan must provide that an IHS facility, meeting State plan requirements for Medicaid participants, must be accepted as a Medicaid provider on the same basis as any other qualified provider.

Program Type 6. Home and Community-Based Care for Functionally Disabled Elderly (See §1929 of the Act) and for Individuals Age 65 and Older(MSIS (See 42 CFR 441, Subpart H).--This program is for §1915(d) recipients of home and community-based services for individuals age 65 or older. This is an option within the Medicaid program to provide home and community-based care to functionally disabled individuals age 65 or older who are otherwise eligible for Medicaid or for non-disabled elderly individuals.

Program Type 7. Home and Community‑Based Waivers (See §1915(c) of the Act and 42 CFR 440.180).--This program includes services furnished under a waiver approved under the provisions in 42 CFR Part 441, Subpart G (home and community-based services; waiver requirements).

ATTACHMENT 4 – New Eligibility Group Table

	ELIGIBILITY GROUP TABLE
Eligibility Group	MAGI	Short Description
	MANDATORY COVERAGE
01	Parents and Other Caretaker Relatives	Parents and other caretaker relatives of dependent children with household income at or below a standard established by the state.
02	Transitional Medical Assistance	Families with Medicaid eligibility extended for up to 12 months because of increased earnings.
03	Extended Medicaid due to Earnings	Families with Medicaid eligibility extended for 4 months because of increased earnings.
04	Extended Medicaid due to Spousal Support Collections	Families with Medicaid eligibility extended for 4 months as the result of the collection of spousal support.
05	Pregnant Women	Women who are pregnant or post-partum, with household income at or below a standard established by the state.
06	Deemed Newborns	Children born to women receiving Medicaid on the date of the child's birth, who are deemed eligible for Medicaid for one year.
07	Infants and Children under Age 19	Infants and children under age 19 with household income at or below standards established by the state based on age group.
08	Title IV-E Subsidized Adoption or Foster Care Children	Individuals for whom an adoption agreement is in effect or foster care maintenance payments are made under title IV-E of the Act.
09	Former Foster Children	Individuals under 26, not otherwise mandatorily eligible, who were on Medicaid and in foster care on their 18th birthday.
10	Individuals at or below 133% FPL Age 19 through 64	Non-pregnant individuals aged 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.
11	Individuals Receiving SSI	Individuals who are aged, blind or disabled who receive SSI.
12	Aged, Blind and Disabled Individuals in 209(b) States	In 209(b) states, aged, blind and disabled individuals who meet more restrictive criteria than used in SSI.
13	Individuals Receiving Mandatory State Supplements	Individuals receiving mandatory State Supplements to SSI benefits.
14	Individuals Who Are Essential Spouses	Individuals who were eligible as essential spouses in 1973 and who continue be essential to the well-being of a recipient of cash assistance.
15	Institutionalized Individuals Continuously Eligible Since 1973	Institutionalized individuals who were eligible for Medicaid in 1973 as inpatients of Title XIX medical institutions or intermediate care facilities, and who continue to meet the 1973 requirements.
16	Blind or Disabled Individuals Eligible in 1973	Blind or disabled individuals who were eligible for Medicaid in 1973 who meet all current requirements for Medicaid except for the blindness or disability criteria.
17	Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI Benefits in 1972	Individuals who would be eligible for SSI/SSP except for the increase in OASDI benefits in 1972, who were entitled to and receiving cash assistance in August, 1972.
18	Individuals Who Would be Eligible for SSI/SSP but for OASDI COLA increases since April, 1977	Individuals who are receiving OASDI and became ineligible for SSI/SSP after April, 1977, who would continue to be eligible if the cost of living increases in OASDI since their last month of eligibility for SSI/SSP/OASDI were deducted from income.
19	Disabled Widows and Widowers Ineligible for SSI due to Increase in OASDI	Disabled widows and widowers who would be eligible for SSI /SSP, except for the increase in OASDI benefits due to the elimination of the reduction factor in P.L. 98-21, who therefore are deemed to be SSI or SSP recipients.
20	Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security	Disabled widows and widowers who would be eligible for SSI/SSP, except for the early receipt of OASDI benefits, who are not entitled to Medicare Part A, who therefore are deemed to be SSI recipients.
21	Working Disabled under 1619(b)	Blind or disabled individuals who participated in Medicaid as SSI cash recipients or who were considered to be receiving SSI, who would still qualify for SSI except for earnings.
22	Disabled Adult Children	Individuals who lose eligibility for SSI at age 18 or older due to receipt of or increase in Title II OASDI child benefits.
23	Qualified Medicare Beneficiaries	Individuals with income equal to or less than 100% of the FPL who are entitled to Medicare Part A, who qualify for Medicare cost-sharing.
24	Qualified Disabled and Working Individuals	Working, disabled individuals with income equal to or less than 200% of the FPL, who are entitled to Medicare Part A under section 1818A, who qualify for payment of Medicare Part A premiums.
25	Specified Low Income Medicare Beneficiaries	Individuals with income between 100% and 120% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part A premiums.
26	Qualifying Individuals	Individuals with income between 120% and 135% of the FPL who are entitled to Medicare Part A, who qualify for payment of Medicare Part B premiums.
	OPTIONS FOR COVERAGE
27	Optional Coverage of Parents and Other Caretaker Relatives	Individuals qualifying as parents or caretaker relatives who are not mandatorily eligible and who have income at or below a standard established by the State.
28	Reasonable Classifications of Individuals under Age 21	Individuals under age 21 who are not mandatorily eligible and who have income at or below a standard established by the State.
29	Children with Non-IV-E Adoption Assistance	Children with special needs for whom there is a non-IV-E adoption assistance agreement, who were or would have been eligible for Medicaid if IV-E requirements were used.
30	Independent Foster Care Adolescents	Individuals under an age specified by the State, less than age 21, who were in State-sponsored foster care on their 18th birthday and who meet the income standard established by the State.
31	Optional Targeted Low Income Children	Uninsured children who have household income at or below a standard established by the State.
32	Individuals Electing COBRA Continuation Coverage	Individuals choosing to continue COBRA benefits with income equal to or less than 100% of the FPL.
33	Individuals above 133% FPL under Age 65	Individuals under 65, not otherwise mandatorily or optionally eligible, with income above 133% FPL and at or below a standard established by the State.
34	Certain Women with Breast or Cervical Cancer	Women under 65 who have been screened for breast or cervical cancer and need treatment.
35	Individuals Eligible for Family Planning Services	Individuals who are not pregnant, with income equal to or below the highest standard for pregnant women, as specified by the State, limited to family planning and related services.
36	Individuals with Tuberculosis	Individuals infected with tuberculosis whose income and resources do not exceed established standards, limited to tuberculosis-related services.
37	Aged, Blind or Disabled Individuals Eligible for but Not Receiving Cash	Individuals who meet the requirements of SSI or Optional State Supplement, but who do not receive cash.
38	Individuals Eligible for Cash except for Institutionalization	Individuals who meet the requirements of AFDC, SSI or Optional State Supplement, and would be eligible if they were not living in a medical institution.
39	Individuals Receiving Home and Community Based Services under Institutional Rules	Individuals who would be eligible for Medicaid under the State Plan if in a medical institution, who would live in an institution if they did not receive home and community based services.
40	Optional State Supplement Recipients - 1634 States, and SSI Criteria States with 1616 Agreements	Individuals in 1634 States and in SSI Criteria States with agreements under 1616, who receive a state supplementary payment (but not SSI).
41	Optional State Supplement Recipients - 209(b) States, and SSI Criteria States without 1616 Agreements	Individuals in 209(b) States and in SSI Criteria States without agreements under 1616, who receive a state supplementary payment (but not SSI).
42	Institutionalized Individuals Eligible under a Special Income Level	Individuals who are in institutions for at least 30 consecutive days who are eligible under a special income level.
43	Individuals participating in a PACE Program under Institutional Rules	Individuals who would be eligible for Medicaid under the State Plan if in a medical institution, who would require institutionalization if they did not participate in the PACE program.
44	Individuals Receiving Hospice Care	Individuals who would be eligible for Medicaid under the State Plan if they were in a medical institution, who are terminally ill, and who will receive hospice care.
45	Qualified Disabled Children under 19	Certain children under 19 living at home, who are disabled and would be eligible if they were living in a medical institution.
46	Poverty Level Aged or Disabled	Individuals who are aged or disabled with income equal to or less than a percentage of the FPL, established by the state (no higher than 100%).
47	Work Incentives Eligibility Group	Individuals with a disability with income below 250% of the FPL, who would qualify for SSI except for earned income.
48	Ticket to Work Basic Group	Individuals with earned income between ages 16 and 65 with a disability, with income and resources equal to or below a standard specified by the State.
49	Ticket to Work Medical Improvements Group	Individuals with earned income between ages 16 and 65 who are no longer disabled but still have a medical impairment, with income and resources equal to or below a standard specified by the State.
50	Family Opportunity Act Children with Disabilities	Children under 19 who are disabled, with income equal to or less than a standard specified by the State (no higher than 300% of the FPL).
51	Individuals Eligible for Home and Community-Based Services	Individuals with income equal to or below 150% of the FPL, who qualify for home and community based services without a determination that they would otherwise live in an institution.

52	Individuals Eligible for Home and Community-Based Services - Special Income Level	Individuals with income equal to or below 300% of the SSI federal benefit rate, who are eligible under a waiver approved for the State, who would live in an institution if they did not receive home and community based services.
	MEDICALLY NEEDY
53	Medically Needy Pregnant Women	Women who are pregnant, who would qualify as categorically needy, except for income..
54	Medically Needy Children under 18	Children under 18 who would qualify as categorically needy, except for income.
55	Medically Needy Children 18 - 20	Children over 18 and under an age established by the State (less than age 21), who would qualify as categorically needy, except for income.
56	Medically Needy Parents and Other Caretakers	Parents and other caretaker relatives of dependent children, eligible as categorically needy except for income.
57	Medically Needy Individuals Age 19 through 64	Non-pregnant individuals ineligible for Medicaid under 42 CFR 435.119 solely due to income.
58	Medically Needy Individuals under Age 65	Individuals ineligible for Medicaid under 42 CFR 435.218 solely due to income.
59	Medically Needy Aged, Blind or Disabled	Individuals who are age 65 or older, blind or disabled, who are not eligible as categorically needy, who meet income and resource standards specified by the State, or who meet the income standard using medical and remedial care expenses to offset excess income.
60	Medically Needy Blind or Disabled Individuals Eligible in 1973	Blind or disabled individuals who were eligible for Medicaid as Medically Needy in 1973 who meet all current requirements for Medicaid except for the blindness or disability criteria.

APPENDIX A: ERROR MESSAGE LIST

The following is a list of the actual error messages that will appear on the Validation Report.

ERROR ERROR

CODE MESSAGE

000 Field has passed all edits

101 Value is not in required format

102 Value is not a valid date

201 Value is not included in the valid code list

202 Value is not one of the allowable file names

203 Value out of range

301 Value is "9-filled"

303 Value is "Space-filled"

304 Value is "0-filled" (invalid default setting)

305 Value is illegally "8-filled"

306 Value is not "8-filled" and field is not applicable.

307 Value is not “0-filled” and field is not applicable

401 Value is inconsistent with the fiscal month specified in the File Label Internal Dataset Name

402 Value is different from file name contained in the File Label Internal Dataset Name

421 Value is not the date immediately following END-OF- TIME-PERIOD in the corresponding Header Record submitted for the previous reporting month

501 Relational edit with DATE-FILE-CREATED failed

502 Relational edit with DAYS-OF-ELIGIBILITY failed

503 Relational edit with MAINTENANCE-ASSISTANCE-STATUS failed

504 Relational edit with DATE-OF-DEATH failed

505 Relational edit with DATE-OF-BIRTH failed

506 Relational edit with END-OF-TIME-PERIOD in Header Record failed

507 Relational edit with STATE-ABBREVIATION failed

508 Relational edit with NURSING-FACILITY-DAYS failed

509 Relational edit with TYPE-OF-CLAIM failed

510 Relational edit with AMOUNT-CHARGED failed

511 Relational edit with BEGINNING-DATE-OF-SERVICE failed

512 Relational edit with ADMISSION-DATE failed

513 Relational edit with DATE-OF-PAYMENT-ADJUDICATION failed

514 Relational edit with START-OF-TIME-PERIOD in Header Record failed

515 Relational edit with MEDICARE-DEDUCTIBLE-AMOUNT failed

516 Relational edit with FILE-NAME failed

517 Relational edit with ENDING-DATE-OF-SERVICE failed

518 Relational edit with TYPE-OF-COVERAGE failed

519 Relational edit with SOCIAL-SECURITY-NUMBER failed

520 Relational edit with MEDICAID-COVERED-INPATIENT-DAYS failed

521 Relational edit with TYPE-OF-SERVICE failed

522 Relational edit with MSIS-IDENTIFICATION-NUMBER failed

523 Relational edit with CHIP-CODE failed

524 Relational edit with PROVIDER-IDENTIFICATION-NUMBER-BILLING failed

525 Relational edit with MOTHER-CHILD-LINK-IND failed

526 Not used

527 Not used

528 Not used

APPENDIX A. ERROR MESSAGE LIST (continued)

ERROR ERROR

CODE MESSAGE

529 Relational edit with TYPE-OF-SERVICE AND PROVIDER-IDENTIFICATION-NUMBER-BILLING

530 Relational edit with SERVICE-CODE failed

531 Relational edit with COUNTY-CODE failed

532 Relational edit among eligibility data element monthly array failed

533 Relational edit with BASIS-OF-ELIGIBILITY failed

534 Relational edit with TANF-FLAG failed

535 Relational edit with PRESCRIPTION-FILL-DATE failed

536 Relational edit with NATIONAL-DRUG-CODE

537 Relational edit with DUAL-ELIGIBLE-FLAG failed

538 Relational edit with corresponding monthly PLAN-TYPE or WAIVER-TYPE field failed

539 Relational edit with SEX-CODE failed

540 Relational edit with DIAGNOSIS-RELATED-GROUP-INDICATOR failed

541 Relational edit with DIAGNOSIS-1 failed

542 Relational edit with PRECEDING DIAGNOSIS failed

550 Relational edit with RACE-ETHNICITY-CODE and ETHNICITY-CODE or RACE-CODE failed

601 Relational edit with FEDERAL-FISCAL-YEAR and FEDERAL-FISCAL-MONTH failed

602 Relational edit with MSIS-IDENTIFICATION-NUMBER failed

603 Relational edit with BEGINNING-DATE-OF-SERVICE and ENDING-DATE-OF-SERVICE failed

604 Relational edit with ACCOMMODATION-CHARGES and AMOUNT-CHARGED failed

605 Relational edit with END-OF-TIME-PERIOD and TYPE-OF-SERVICE failed

606 Relational edit with MEDICARE-DEDUCTIBLE-AMOUNT and AMOUNT-CHARGED failed

607 Relational edit with ADJUSTMENT-INDICATOR failed

608 Relational edit with ICF/MR Days failed

701 Relational edit with FEDERAL-FISCAL-YEAR, FEDERAL-FISCAL-MONTH, and TYPE-OF-RECORD failed

702 Relational edit with DATE-OF-BIRTH, MAINTENANCE-ASSISTANCE-STATUS, and DAYS-OF-ELIGIBILITY failed

703 Relational edit with MSIS-IDENTIFICATION-NUMBER, TEMPORARY-IDENTIFICATION-NUMBER failed

704 Relational edit with AMOUNT-CHARGED, MEDICARE-COINSURANCE-PAYMENT, and MEDICARE-DEDUCTIBLE-PAYMENT failed

801 Duplicate Eligible Record (Exact match on: ID, FFY, QTR, SEX, DOB)

802 Non-Unique Duplicate Eligible Record (Exact match on: ID, FFY, QTR, SEX and/or DOB do not match)

803 Duplicate Claim Record - 100% match on all fields

810 Non-Numeric Value Provided - -

811 Non-Numeric Value Provided - Reset to 8-filled

812 Non-Numeric Value Provided - --filled

813 Non-Numeric Value Provided - Reset to 41(obsolete)

814 Non-Numeric Value Provided in Header Record

996 INFORMATIONAL - Value = 1 and DATE-OF-BIRTH implies Recipient was not over 64 on the first day of the month

997 INFORMATIONAL - Value not consistent with eligible’s age

998 INFORMATIONAL - State specific values not available

999 INFORMATIONAL - Relational edit not performed because the related field was already flagged in error

CQC CURRENT MONTH CHECK - File appears to be for the wrong month. More than 50% of the Current Month records contained within the first 500 records of the file are outside of the reporting month. Comparison is done between the beginning and ending month dates of the file header record versus the Date-of-Payment-Adjudication on each data record.

APPENDIX B: Claim Adjustment Reason Codes

Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code.

1	Deductible Amount Start: 01/01/1995
2	Coinsurance Amount Start: 01/01/1995
3	Co-payment Amount Start: 01/01/1995
4	The procedure code is inconsistent with the modifier used or a required modifier is missing. This change to be effective 7/1/2010: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
5	The procedure code/bill type is inconsistent with the place of service. This change to be effective 7/1/2010: The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
6	The procedure/revenue code is inconsistent with the patient's age. This change to be effective 7/1/2010: The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
7	The procedure/revenue code is inconsistent with the patient's gender. This change to be effective 7/1/2010: The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
8	The procedure code is inconsistent with the provider type/specialty (taxonomy). This change to be effective 7/1/2010: The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
9	The diagnosis is inconsistent with the patient's age. This change to be effective 7/1/2010: The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
10	The diagnosis is inconsistent with the patient's gender. This change to be effective 7/1/2010: The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
11	The diagnosis is inconsistent with the procedure. This change to be effective 7/1/2010: The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
12	The diagnosis is inconsistent with the provider type. This change to be effective 7/1/2010: The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
13	The date of death precedes the date of service. Start: 01/01/1995
14	The date of birth follows the date of service. Start: 01/01/1995
15	The authorization number is missing, invalid, or does not apply to the billed services or provider. Start: 01/01/1995 \| Last Modified: 09/30/2007
16	Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 7/1/2010: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/01/1995 \| Last Modified: 09/20/2009
17	Requested information was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) Start: 01/01/1995 \| Last Modified: 09/21/2008 \| Stop: 07/01/2009
18	Duplicate claim/service. Start: 01/01/1995
19	This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007
20	This injury/illness is covered by the liability carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007
21	This injury/illness is the liability of the no-fault carrier. Start: 01/01/1995 \| Last Modified: 09/30/2007
22	This care may be covered by another payer per coordination of benefits. Start: 01/01/1995 \| Last Modified: 09/30/2007
23	The impact of prior payer(s) adjudication including payments and/or adjustments. Start: 01/01/1995 \| Last Modified: 09/30/2007
24	Charges are covered under a capitation agreement/managed care plan. Start: 01/01/1995 \| Last Modified: 09/30/2007
25	Payment denied. Your Stop loss deductible has not been met. Start: 01/01/1995 \| Stop: 04/01/2008
26	Expenses incurred prior to coverage. Start: 01/01/1995
27	Expenses incurred after coverage terminated. Start: 01/01/1995
28	Coverage not in effect at the time the service was provided. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Redundant to codes 26&27.
29	The time limit for filing has expired. Start: 01/01/1995
30	Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or residency requirements. Start: 01/01/1995 \| Stop: 02/01/2006
31	Patient cannot be identified as our insured. Start: 01/01/1995 \| Last Modified: 09/30/2007
32	Our records indicate that this dependent is not an eligible dependent as defined. Start: 01/01/1995
33	Insured has no dependent coverage. Start: 01/01/1995 \| Last Modified: 09/30/2007
34	Insured has no coverage for newborns. Start: 01/01/1995 \| Last Modified: 09/30/2007
35	Lifetime benefit maximum has been reached. Start: 01/01/1995 \| Last Modified: 10/31/2002
36	Balance does not exceed co-payment amount. Start: 01/01/1995 \| Stop: 10/16/2003
37	Balance does not exceed deductible. Start: 01/01/1995 \| Stop: 10/16/2003
38	Services not provided or authorized by designated (network/primary care) providers. Start: 01/01/1995 \| Last Modified: 06/30/2003
39	Services denied at the time authorization/pre-certification was requested. Start: 01/01/1995
40	Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment, if present. This change to be effective 07/01/2010: Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
41	Discount agreed to in Preferred Provider contract. Start: 01/01/1995 \| Stop: 10/16/2003
42	Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45) Start: 01/01/1995 \| Last Modified: 10/31/2006 \| Stop: 06/01/2007
43	Gramm-Rudman reduction. Start: 01/01/1995 \| Stop: 07/01/2006
44	Prompt-pay discount. Start: 01/01/1995
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability). Start: 01/01/1995 \| Last Modified: 10/31/2006
46	This (these) service(s) is (are) not covered. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 96.
47	This (these) diagnosis(es) is (are) not covered, missing, or are invalid. Start: 01/01/1995 \| Stop: 02/01/2006
48	This (these) procedure(s) is (are) not covered. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 96.
49	These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. This change to be effective 7/1/2010: These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
50	These are non-covered services because this is not deemed a 'medical necessity' by the payer. This change to be effective 07/01/2010: These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
51	These are non-covered services because this is a pre-existing condition. This change to be effective 7/1/2010: These are non-covered services because this is a pre-existing condition. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
52	The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service billed. Start: 01/01/1995 \| Stop: 02/01/2006
53	Services by an immediate relative or a member of the same household are not covered. Start: 01/01/1995
54	Multiple physicians/assistants are not covered in this case. This change to be effective 07/01/2010: Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
55	Procedure/treatment is deemed experimental/investigational by the payer. This change to be effective 07/01/2010: Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
56	Procedure/treatment has not been deemed 'proven to be effective' by the payer. This change to be effective 7/1/2010: Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
57	Payment denied/reduced because the payer deems the information submitted does not support this level of service, this many services, this length of service, this dosage, or this day's supply. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Split into codes 150, 151, 152, 153 and 154.
58	Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. This change to be effective 07/01/2010: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
59	Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) This change to be effective 07/01/2010: Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
60	Charges for outpatient services are not covered when performed within a period of time prior to or after inpatient services. Start: 01/01/1995 \| Last Modified: 06/01/2008
61	Penalty for failure to obtain second surgical opinion. This change to be effective 7/1/2010: Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
62	Payment denied/reduced for absence of, or exceeded, pre-certification/authorization. Start: 01/01/1995 \| Last Modified: 10/31/2006 \| Stop: 04/01/2007
63	Correction to a prior claim. Start: 01/01/1995 \| Stop: 10/16/2003
64	Denial reversed per Medical Review. Start: 01/01/1995 \| Stop: 10/16/2003
65	Procedure code was incorrect. This payment reflects the correct code. Start: 01/01/1995 \| Stop: 10/16/2003
66	Blood Deductible. Start: 01/01/1995
67	Lifetime reserve days. (Handled in QTY, QTY01=LA) Start: 01/01/1995 \| Stop: 10/16/2003
68	DRG weight. (Handled in CLP12) Start: 01/01/1995 \| Stop: 10/16/2003
69	Day outlier amount. Start: 01/01/1995
70	Cost outlier - Adjustment to compensate for additional costs. Start: 01/01/1995 \| Last Modified: 06/30/2001
71	Primary Payer amount. Start: 01/01/1995 \| Stop: 06/30/2000 Notes: Use code 23.
72	Coinsurance day. (Handled in QTY, QTY01=CD) Start: 01/01/1995 \| Stop: 10/16/2003
73	Administrative days. Start: 01/01/1995 \| Stop: 10/16/2003
74	Indirect Medical Education Adjustment. Start: 01/01/1995
75	Direct Medical Education Adjustment. Start: 01/01/1995
76	Disproportionate Share Adjustment. Start: 01/01/1995
77	Covered days. (Handled in QTY, QTY01=CA) Start: 01/01/1995 \| Stop: 10/16/2003
78	Non-Covered days/Room charge adjustment. Start: 01/01/1995
79	Cost Report days. (Handled in MIA15) Start: 01/01/1995 \| Stop: 10/16/2003
80	Outlier days. (Handled in QTY, QTY01=OU) Start: 01/01/1995 \| Stop: 10/16/2003
81	Discharges. Start: 01/01/1995 \| Stop: 10/16/2003
82	PIP days. Start: 01/01/1995 \| Stop: 10/16/2003
83	Total visits. Start: 01/01/1995 \| Stop: 10/16/2003
84	Capital Adjustment. (Handled in MIA) Start: 01/01/1995 \| Stop: 10/16/2003
85	Patient Interest Adjustment (Use Only Group code PR) Start: 01/01/1995 \| Last Modified: 07/09/2007 Notes: Only use when the payment of interest is the responsibility of the patient.
86	Statutory Adjustment. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Duplicative of code 45.
87	Transfer amount. Start: 01/01/1995 \| Last Modified: 09/20/2009 \| Stop: 01/01/2012
88	Adjustment amount represents collection against receivable created in prior overpayment. Start: 01/01/1995 \| Stop: 06/30/2007
89	Professional fees removed from charges. Start: 01/01/1995
90	Ingredient cost adjustment. This change to be effective 04/01/2010: Ingredient cost adjustment. Note: To be used for pharmaceuticals only. Start: 01/01/1995 \| Last Modified: 07/01/2009
91	Dispensing fee adjustment. Start: 01/01/1995
92	Claim Paid in full. Start: 01/01/1995 \| Stop: 10/16/2003
93	No Claim level Adjustments. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: As of 004010, CAS at the claim level is optional.
94	Processed in Excess of charges. Start: 01/01/1995
95	Plan procedures not followed. Start: 01/01/1995 \| Last Modified: 09/30/2007
96	Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 7/1/2010: Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
97	The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. This change to be effective 7/1/2010: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
98	The hospital must file the Medicare claim for this inpatient non-physician service. Start: 01/01/1995 \| Stop: 10/16/2003
99	Medicare Secondary Payer Adjustment Amount. Start: 01/01/1995 \| Stop: 10/16/2003
100	Payment made to patient/insured/responsible party/employer. Start: 01/01/1995 \| Last Modified: 01/27/2008
101	Predetermination: anticipated payment upon completion of services or claim adjudication. Start: 01/01/1995 \| Last Modified: 02/28/1999
102	Major Medical Adjustment. Start: 01/01/1995
103	Provider promotional discount (e.g., Senior citizen discount). Start: 01/01/1995 \| Last Modified: 06/30/2001
104	Managed care withholding. Start: 01/01/1995
105	Tax withholding. Start: 01/01/1995
106	Patient payment option/election not in effect. Start: 01/01/1995
107	The related or qualifying claim/service was not identified on this claim. This change to be effective 7/1/2010: The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
108	Rent/purchase guidelines were not met. This change to be effective 7/1/2010: Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
109	Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. Start: 01/01/1995
110	Billing date predates service date. Start: 01/01/1995
111	Not covered unless the provider accepts assignment. Start: 01/01/1995
112	Service not furnished directly to the patient and/or not documented. Start: 01/01/1995 \| Last Modified: 09/30/2007
113	Payment denied because service/procedure was provided outside the United States or as a result of war. Start: 01/01/1995 \| Last Modified: 02/28/2001 \| Stop: 06/30/2007 Notes: Use Codes 157, 158 or 159.
114	Procedure/product not approved by the Food and Drug Administration. Start: 01/01/1995
115	Procedure postponed, canceled, or delayed. Start: 01/01/1995 \| Last Modified: 09/30/2007
116	The advance indemnification notice signed by the patient did not comply with requirements. Start: 01/01/1995 \| Last Modified: 09/30/2007
117	Transportation is only covered to the closest facility that can provide the necessary care. Start: 01/01/1995 \| Last Modified: 09/30/2007
118	ESRD network support adjustment. Start: 01/01/1995 \| Last Modified: 09/30/2007
119	Benefit maximum for this time period or occurrence has been reached. Start: 01/01/1995 \| Last Modified: 02/29/2004
120	Patient is covered by a managed care plan. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 24.
121	Indemnification adjustment - compensation for outstanding member responsibility. Start: 01/01/1995 \| Last Modified: 09/30/2007
122	Psychiatric reduction. Start: 01/01/1995
123	Payer refund due to overpayment. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Refer to implementation guide for proper handling of reversals.
124	Payer refund amount - not our patient. Start: 01/01/1995 \| Last Modified: 06/30/1999 \| Stop: 06/30/2007 Notes: Refer to implementation guide for proper handling of reversals.
125	Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 7/1/2010: Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/01/1995 \| Last Modified: 09/20/2009
126	Deductible -- Major Medical Start: 02/28/1997 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008 Notes: Use Group Code PR and code 1.
127	Coinsurance -- Major Medical Start: 02/28/1997 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008 Notes: Use Group Code PR and code 2.
128	Newborn's services are covered in the mother's Allowance. Start: 02/28/1997
129	Prior processing information appears incorrect. Start: 02/28/1997 \| Last Modified: 09/30/2007
130	Claim submission fee. Start: 02/28/1997 \| Last Modified: 06/30/2001
131	Claim specific negotiated discount. Start: 02/28/1997
132	Prearranged demonstration project adjustment. Start: 02/28/1997
133	The disposition of this claim/service is pending further review. Start: 02/28/1997 \| Last Modified: 10/31/1999
134	Technical fees removed from charges. Start: 10/31/1998
135	Interim bills cannot be processed. Start: 10/31/1998 \| Last Modified: 09/30/2007
136	Failure to follow prior payer's coverage rules. (Use Group Code OA). Start: 10/31/1998 \| Last Modified: 09/30/2007
137	Regulatory Surcharges, Assessments, Allowances or Health Related Taxes. Start: 02/28/1999 \| Last Modified: 09/30/2007
138	Appeal procedures not followed or time limits not met. Start: 06/30/1999 \| Last Modified: 09/30/2007
139	Contracted funding agreement - Subscriber is employed by the provider of services. Start: 06/30/1999
140	Patient/Insured health identification number and name do not match. Start: 06/30/1999
141	Claim spans eligible and ineligible periods of coverage. Start: 06/30/1999 \| Last Modified: 09/30/2007
142	Monthly Medicaid patient liability amount. Start: 06/30/2000 \| Last Modified: 09/30/2007
143	Portion of payment deferred. Start: 02/28/2001
144	Incentive adjustment, e.g. preferred product/service. Start: 06/30/2001
145	Premium payment withholding Start: 06/30/2002 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008 Notes: Use Group Code CO and code 45.
146	Diagnosis was invalid for the date(s) of service reported. Start: 06/30/2002 \| Last Modified: 09/30/2007
147	Provider contracted/negotiated rate expired or not on file. Start: 06/30/2002
148	Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 7/1/2010: Information from another provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 06/30/2002 \| Last Modified: 09/20/2009
149	Lifetime benefit maximum has been reached for this service/benefit category. Start: 10/31/2002
150	Payer deems the information submitted does not support this level of service. Start: 10/31/2002 \| Last Modified: 09/30/2007
151	Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Start: 10/31/2002 \| Last Modified: 01/27/2008
152	Payer deems the information submitted does not support this length of service. This change to be effective 7/1/2010: Payer deems the information submitted does not support this length of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 10/31/2002 \| Last Modified: 09/20/2009
153	Payer deems the information submitted does not support this dosage. Start: 10/31/2002 \| Last Modified: 09/30/2007
154	Payer deems the information submitted does not support this day's supply. Start: 10/31/2002 \| Last Modified: 09/30/2007
155	Patient refused the service/procedure. Start: 06/30/2003 \| Last Modified: 09/30/2007
156	Flexible spending account payments. Note: Use code 187. Start: 09/30/2003 \| Last Modified: 01/25/2009 \| Stop: 10/01/2009
157	Service/procedure was provided as a result of an act of war. Start: 09/30/2003 \| Last Modified: 09/30/2007
158	Service/procedure was provided outside of the United States. Start: 09/30/2003 \| Last Modified: 09/30/2007
159	Service/procedure was provided as a result of terrorism. Start: 09/30/2003 \| Last Modified: 09/30/2007
160	Injury/illness was the result of an activity that is a benefit exclusion. Start: 09/30/2003 \| Last Modified: 09/30/2007
161	Provider performance bonus Start: 02/29/2004
162	State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for specific explanation. Start: 02/29/2004
163	Attachment referenced on the claim was not received. Start: 06/30/2004 \| Last Modified: 09/30/2007
164	Attachment referenced on the claim was not received in a timely fashion. Start: 06/30/2004 \| Last Modified: 09/30/2007
165	Referral absent or exceeded. Start: 10/31/2004 \| Last Modified: 09/30/2007
166	These services were submitted after this payers responsibility for processing claims under this plan ended. Start: 02/28/2005
167	This (these) diagnosis(es) is (are) not covered. This change to be effective 7/1/2010: This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
168	Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan. Start: 06/30/2005 \| Last Modified: 09/30/2007
169	Alternate benefit has been provided. Start: 06/30/2005 \| Last Modified: 09/30/2007
170	Payment is denied when performed/billed by this type of provider. This change to be effective 7/1/2010: Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
171	Payment is denied when performed/billed by this type of provider in this type of facility. This change to be effective 7/1/2010: Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
172	Payment is adjusted when performed/billed by a provider of this specialty. This change to be effective 7/1/2010: Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
173	Service was not prescribed by a physician. Start: 06/30/2005 \| Last Modified: 09/30/2007
174	Service was not prescribed prior to delivery. Start: 06/30/2005 \| Last Modified: 09/30/2007
175	Prescription is incomplete. Start: 06/30/2005 \| Last Modified: 09/30/2007
176	Prescription is not current. Start: 06/30/2005 \| Last Modified: 09/30/2007
177	Patient has not met the required eligibility requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007
178	Patient has not met the required spend down requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007
179	Patient has not met the required waiting requirements. This change to be effective 7/1/2010: Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
180	Patient has not met the required residency requirements. Start: 06/30/2005 \| Last Modified: 09/30/2007
181	Procedure code was invalid on the date of service. Start: 06/30/2005 \| Last Modified: 09/30/2007
182	Procedure modifier was invalid on the date of service. Start: 06/30/2005 \| Last Modified: 09/30/2007
183	The referring provider is not eligible to refer the service billed. This change to be effective 7/1/2010: The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
184	The prescribing/ordering provider is not eligible to prescribe/order the service billed. This change to be effective 7/1/2010: The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
185	The rendering provider is not eligible to perform the service billed. This change to be effective 7/1/2010: The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/30/2005 \| Last Modified: 09/20/2009
186	Level of care change adjustment. Start: 06/30/2005 \| Last Modified: 09/30/2007
187	Consumer Spending Account payments (includes but is not limited to Flexible Spending Account, Health Savings Account, Health Reimbursement Account, etc.) Start: 06/30/2005 \| Last Modified: 01/25/2009
188	This product/procedure is only covered when used according to FDA recommendations. Start: 06/30/2005
189	'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service Start: 06/30/2005
190	Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay. Start: 10/31/2005
191	Not a work related injury/illness and thus not the liability of the workers' compensation carrier. Start: 10/31/2005 \| Last Modified: 09/30/2007
192	Non standard adjustment code from paper remittance. Note: This code is to be used by providers/payers providing Coordination of Benefits information to another payer in the 837 transaction only. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment. Start: 10/31/2005 \| Last Modified: 09/30/2007
193	Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. Start: 02/28/2006 \| Last Modified: 01/27/2008
194	Anesthesia performed by the operating physician, the assistant surgeon or the attending physician. Start: 02/28/2006 \| Last Modified: 09/30/2007
195	Refund issued to an erroneous priority payer for this claim/service. Start: 02/28/2006 \| Last Modified: 09/30/2007
196	Claim/service denied based on prior payer's coverage determination. Start: 06/30/2006 \| Stop: 02/01/2007 Notes: Use code 136.
197	Precertification/authorization/notification absent. Start: 10/31/2006 \| Last Modified: 09/30/2007
198	Precertification/authorization exceeded. Start: 10/31/2006 \| Last Modified: 09/30/2007
199	Revenue code and Procedure code do not match. Start: 10/31/2006
200	Expenses incurred during lapse in coverage Start: 10/31/2006
201	Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC 'Medicare set aside arrangement' or other agreement. (Use group code PR). Start: 10/31/2006
202	Non-covered personal comfort or convenience services. Start: 02/28/2007 \| Last Modified: 09/30/2007
203	Discontinued or reduced service. Start: 02/28/2007 \| Last Modified: 09/30/2007
204	This service/equipment/drug is not covered under the patient's current benefit plan Start: 02/28/2007
205	Pharmacy discount card processing fee Start: 07/09/2007
206	National Provider Identifier - missing. Start: 07/09/2007 \| Last Modified: 09/30/2007
207	National Provider identifier - Invalid format Start: 07/09/2007 \| Last Modified: 06/01/2008
208	National Provider Identifier - Not matched. Start: 07/09/2007 \| Last Modified: 09/30/2007
209	Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group code OA) Start: 07/09/2007
210	Payment adjusted because pre-certification/authorization not received in a timely fashion Start: 07/09/2007
211	National Drug Codes (NDC) not eligible for rebate, are not covered. Start: 07/09/2007
212	Administrative surcharges are not covered Start: 11/05/2007
213	Non-compliance with the physician self referral prohibition legislation or payer policy. Start: 01/27/2008
214	Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or service/treatment. (Note: To be used for Workers' Compensation only) Start: 01/27/2008
215	Based on subrogation of a third party settlement Start: 01/27/2008
216	Based on the findings of a review organization Start: 01/27/2008
217	Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee arrangement. (Note: To be used for Workers' Compensation only) Start: 01/27/2008
218	Based on entitlement to benefits (Note: To be used for Workers' Compensation only) Start: 01/27/2008
219	Based on extent of injury (Note: To be used for Workers' Compensation only) Start: 01/27/2008
220	The applicable fee schedule does not contain the billed code. Please resubmit a bill with the appropriate fee schedule code(s) that best describe the service(s) provided and supporting documentation if required. (Note: To be used for Workers' Compensation only) Start: 01/27/2008
221	Workers' Compensation claim is under investigation. (Note: To be used for Workers' Compensation only. Claim pending final resolution) Start: 01/27/2008
222	Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. This change to be effective 7/1/2010: Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 06/01/2008 \| Last Modified: 09/20/2009
223	Adjustment code for mandated federal, state or local law/regulation that is not already covered by another code and is mandated before a new code can be created. Start: 06/01/2008
224	Patient identification compromised by identity theft. Identity verification required for processing this and future claims. Start: 06/01/2008
225	Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837) Start: 06/01/2008
226	Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 7/1/2010: Information requested from the Billing/Rendering Provider was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 09/21/2008 \| Last Modified: 09/20/2009
227	Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 7/1/2010: Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 09/21/2008 \| Last Modified: 09/20/2009
228	Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication Start: 09/21/2008
229	Partial charge amount not considered by Medicare due to the initial claim Type of Bill being 12X. Note: This code can only be used in the 837 transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer. Use Group Code PR. Start: 01/25/2009
230	No available or correlating CPT/HCPCS code to describe this service. Note: Used only by Property and Casualty. Start: 01/25/2009
231	Mutually exclusive procedures cannot be done in the same day/setting. This change to be effective 7/1/2010: Mutually exclusive procedures cannot be done in the same day/setting. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 07/01/2009 \| Last Modified: 09/20/2009
232	Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Start: 11/01/2009
233	Services/charges related to the treatment of a hospital-acquired condition or preventable medical error. Start: 01/24/2010
234	This procedure is not paid separately. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/24/2010
A0	Patient refund amount. Start: 01/01/1995
A1	Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) This change to be effective 7/1/2010: Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 01/01/1995 \| Last Modified: 09/20/2009
A2	Contractual adjustment. Start: 01/01/1995 \| Last Modified: 02/28/2007 \| Stop: 01/01/2008 Notes: Use Code 45 with Group Code 'CO' or use another appropriate specific adjustment code.
A3	Medicare Secondary Payer liability met. Start: 01/01/1995 \| Stop: 10/16/2003
A4	Medicare Claim PPS Capital Day Outlier Amount. Start: 01/01/1995 \| Last Modified: 09/30/2007 \| Stop: 04/01/2008
A5	Medicare Claim PPS Capital Cost Outlier Amount. Start: 01/01/1995
A6	Prior hospitalization or 30 day transfer requirement not met. Start: 01/01/1995
A7	Presumptive Payment Adjustment Start: 01/01/1995
A8	Ungroup able DRG. Start: 01/01/1995 \| Last Modified: 09/30/2007
B1	Non-covered visits. Start: 01/01/1995
B2	Covered visits. Start: 01/01/1995 \| Stop: 10/16/2003
B3	Covered charges. Start: 01/01/1995 \| Stop: 10/16/2003
B4	Late filing penalty. Start: 01/01/1995
B5	Coverage/program guidelines were not met or were exceeded. Start: 01/01/1995 \| Last Modified: 09/30/2007
B6	This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty. Start: 01/01/1995 \| Stop: 02/01/2006
B7	This provider was not certified/eligible to be paid for this procedure/service on this date of service. This change to be effective 7/1/2010: This provider was not certified/eligible to be paid for this procedure/service on this date of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
B8	Alternative services were available, and should have been utilized. This change to be effective 7/1/2010: Alternative services were available, and should have been utilized. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
B9	Patient is enrolled in a Hospice. Start: 01/01/1995 \| Last Modified: 09/30/2007
B10	Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test. Start: 01/01/1995
B11	The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. Start: 01/01/1995
B12	Services not documented in patients' medical records. Start: 01/01/1995
B13	Previously paid. Payment for this claim/service may have been provided in a previous payment. Start: 01/01/1995
B14	Only one visit or consultation per physician per day is covered. Start: 01/01/1995 \| Last Modified: 09/30/2007
B15	This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. This change to be effective 7/1/2010: This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 \| Last Modified: 09/20/2009
B16	'New Patient' qualifications were not met. Start: 01/01/1995 \| Last Modified: 09/30/2007
B17	Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete, or the prescription is not current. Start: 01/01/1995 \| Stop: 02/01/2006
B18	This procedure code and modifier were invalid on the date of service. Start: 01/01/1995 \| Last Modified: 09/21/2008 \| Stop: 03/01/2009
B19	Claim/service adjusted because of the finding of a Review Organization. Start: 01/01/1995 \| Stop: 10/16/2003
B20	Procedure/service was partially or fully furnished by another provider. Start: 01/01/1995 \| Last Modified: 09/30/2007
B21	The charges were reduced because the service/care was partially furnished by another physician. Start: 01/01/1995 \| Stop: 10/16/2003
B22	This payment is adjusted based on the diagnosis. Start: 01/01/1995 \| Last Modified: 02/28/2001
B23	Procedure billed is not authorized per your Clinical Laboratory Improvement Amendment (CLIA) proficiency test. Start: 01/01/1995 \| Last Modified: 09/30/2007
D1	Claim/service denied. Level of subluxation is missing or inadequate. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D2	Claim lacks the name, strength, or dosage of the drug furnished. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D3	Claim/service denied because information to indicate if the patient owns the equipment that requires the part or supply was missing. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D4	Claim/service does not indicate the period of time for which this will be needed. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D5	Claim/service denied. Claim lacks individual lab codes included in the test. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D6	Claim/service denied. Claim did not include patient's medical record for the service. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D7	Claim/service denied. Claim lacks date of patient's most recent physician visit. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D8	Claim/service denied. Claim lacks indicator that 'x-ray is available for review.' Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D9	Claim/service denied. Claim lacks invoice or statement certifying the actual cost of the lens, less discounts or the type of intraocular lens used. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 16 and remark codes if necessary.
D10	Claim/service denied. Completed physician financial relationship form not on file. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D11	Claim lacks completed pacemaker registration form. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D12	Claim/service denied. Claim does not identify who performed the purchased diagnostic test or the amount you were charged for the test. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D13	Claim/service denied. Performed by a facility/supplier in which the ordering/referring physician has a financial interest. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D14	Claim lacks indication that plan of treatment is on file. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D15	Claim lacks indication that service was supervised or evaluated by a physician. Start: 01/01/1995 \| Stop: 10/16/2003 Notes: Use code 17.
D16	Claim lacks prior payer payment information. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code [N4].
D17	Claim/Service has invalid non-covered days. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D18	Claim/Service has missing diagnosis information. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D19	Claim/Service lacks Physician/Operative or other supporting documentation Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D20	Claim/Service missing service/product information. Start: 01/01/1995 \| Stop: 06/30/2007 Notes: Use code 16 with appropriate claim payment remark code.
D21	This (these) diagnosis(es) is (are) missing or are invalid Start: 01/01/1995 \| Stop: 06/30/2007
D22	Reimbursement was adjusted for the reasons to be provided in separate correspondence. (Note: To be used for Workers' Compensation only) - Temporary code to be added for timeframe only until 01/01/2009. Another code to be established and/or for 06/2008 meeting for a revised code to replace or strategy to use another existing code Start: 01/27/2008 \| Stop: 01/01/2009
D23	This dual eligible patient is covered by Medicare Part D per Medicare Retro-Eligibility. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Start: 11/01/2009 \| Stop: 01/01/2012
W1	Workers Compensation State Fee Schedule Adjustment Start: 02/29/2000

APPENDIX C: Remittance Advice Remark Codes - 7/1/2009 - Current

Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List.

X-ray not taken within the past 12 months or near enough to the start of treatment.
Start: 01/01/1997

Not paid separately when the patient is an inpatient.
Start: 01/01/1997

Equipment is the same or similar to equipment already being used.
Start: 01/01/1997

Alert: This is the last monthly installment payment for this durable medical equipment.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.
Start: 01/01/1997

Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment.
Start: 01/01/1997 | Last Modified: 03/01/2009
Notes: (Modified 4/1/07, 3/1/2009)

No rental payments after the item is purchased, or after the total of issued rental payments equals the purchase price.
Start: 01/01/1997

We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen.
Start: 01/01/1997

Alert: This is the tenth rental month. You must offer the patient the choice of changing the rental to a purchase agreement.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

M10

Equipment purchases are limited to the first or the tenth month of medical necessity.
Start: 01/01/1997

M11

DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code.
Start: 01/01/1997

M12

Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.
Start: 01/01/1997

M13

Only one initial visit is covered per specialty per medical group.
Start: 01/01/1997 | Last Modified: 06/30/2007
Notes: (Modified 6/30/03)

M14

No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.
Start: 01/01/1997

M15

Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
Start: 01/01/1997

M16

Alert: Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Reactivated 4/1/04, Modified 11/18/05, 4/1/07)

M17

Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. In the future, you will be liable for charges for the same service(s) under the same or similar conditions.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

M18

Certain services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient's home.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

M19

Missing oxygen certification/re-certification.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N234

M20

Missing/incomplete/invalid HCPCS.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M21

Missing/incomplete/invalid place of residence for this service/item provided in a home.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M22

Missing/incomplete/invalid number of miles traveled.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M23

Missing invoice.
Start: 01/01/1997 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05)

M24

Missing/incomplete/invalid number of doses per vial.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M25

The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request a appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07)

M26

The information furnished does not substantiate the need for this level of service. If you have collected any amount from the patient for this level of service /any amount that exceeds the limiting charge for the less extensive service, the law requires you to refund that amount to the patient within 30 days of receiving this notice.

The requirements for refund are in 1824(I) of the Social Security Act and 42CFR411.408. The section specifies that physicians who knowingly and willfully fail to make appropriate refunds may be subject to civil monetary penalties and/or exclusion from the program. If you have any questions about this notice, please contact this office.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 10/1/02, 6/30/03, 8/1/05, 11/5/07. Also refer to N356)

M27

Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered. You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive this notice. You must make the request through this office.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 10/1/02, 8/1/05, 4/1/07, 8/1/07)

M28

This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available.
Start: 01/01/1997

M29

Missing operative note/report.
Start: 01/01/1997 | Last Modified: 07/01/2008
Notes: (Modified 2/28/03, 7/1/2008) Related to N233

M30

Missing pathology report.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04, 2/28/03) Related to N236

M31

Missing radiology report.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04, 2/28/03) Related to N240

M32

Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer. You must contact this office immediately upon receipt of an additional payment for this service.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

M36

This is the 11th rental month. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.
Start: 01/01/1997

M37

Service not covered when the patient is under age 35.
Start: 01/01/1997

M38

The patient is liable for the charges for this service as you informed the patient in writing before the service was furnished that we would not pay for it, and the patient agreed to pay.
Start: 01/01/1997

M39

Alert: The patient is not liable for payment for this service as the advance notice of non-coverage you provided the patient did not comply with program requirements.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 2/1/04, 4/1/07)

M40

Claim must be assigned and must be filed by the practitioner's employer.
Start: 01/01/1997

M41

We do not pay for this as the patient has no legal obligation to pay for this.
Start: 01/01/1997

M42

The medical necessity form must be personally signed by the attending physician.
Start: 01/01/1997

M44

Missing/incomplete/invalid condition code.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M45

Missing/incomplete/invalid occurrence code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N299

M46

Missing/incomplete/invalid occurrence span code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N300

M47

Missing/incomplete/invalid internal or document control number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M49

Missing/incomplete/invalid value code(s) or amount(s).
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M50

Missing/incomplete/invalid revenue code(s).
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M51

Missing/incomplete/invalid procedure code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N301

M52

Missing/incomplete/invalid "from" date(s) of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M53

Missing/incomplete/invalid days or units of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M54

Missing/incomplete/invalid total charges.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M55

We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug.
Start: 01/01/1997

M56

Missing/incomplete/invalid payer identifier.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M59

Missing/incomplete/invalid "to" date(s) of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M60

Missing Certificate of Medical Necessity.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04, 6/30/03) Related to N227

M61

We cannot pay for this as the approval period for the FDA clinical trial has expired.
Start: 01/01/1997

M62

Missing/incomplete/invalid treatment authorization code.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M64

Missing/incomplete/invalid other diagnosis.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M65

One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Please submit a separate claim for each interpreting physician.
Start: 01/01/1997

M66

Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items.
Start: 01/01/1997

M67

Missing/incomplete/invalid other procedure code(s).
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N302

M69

Paid at the regular rate as you did not submit documentation to justify the modified procedure code.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)

M70

Alert: The NDC code submitted for this service was translated to a HCPCS code for processing, but please continue to submit the NDC on future claims for this item.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 4/1/2007, 8/1/07)

M71

Total payment reduced due to overlap of tests billed.
Start: 01/01/1997

M73

The HPSA/Physician Scarcity bonus can only be paid on the professional component of this service. Rebill as separate professional and technical components.
Start: 01/01/1997 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04)

M74

This service does not qualify for a HPSA/Physician Scarcity bonus payment.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)

M75

Multiple automated multichannel tests performed on the same day combined for payment.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)

M76

Missing/incomplete/invalid diagnosis or condition.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M77

Missing/incomplete/invalid place of service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M79

Missing/incomplete/invalid charge.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M80

Not covered when performed during the same session/date as a previously processed service for the patient.
Start: 01/01/1997 | Last Modified: 10/31/2002
Notes: (Modified 10/31/02)

M81

You are required to code to the highest level of specificity.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)

M82

Service is not covered when patient is under age 50.
Start: 01/01/1997

M83

Service is not covered unless the patient is classified as at high risk.
Start: 01/01/1997

M84

Medical code sets used must be the codes in effect at the time of service
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)

M85

Subjected to review of physician evaluation and management services.
Start: 01/01/1997

M86

Service denied because payment already made for same/similar procedure within set time frame.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

M87

Claim/service(s) subjected to CFO-CAP prepayment review.
Start: 01/01/1997

M89

Not covered more than once under age 40.
Start: 01/01/1997

M90

Not covered more than once in a 12 month period.
Start: 01/01/1997

M91

Lab procedures with different CLIA certification numbers must be billed on separate claims.
Start: 01/01/1997

M93

Information supplied supports a break in therapy. A new capped rental period began with delivery of this equipment.
Start: 01/01/1997

M94

Information supplied does not support a break in therapy. A new capped rental period will not begin.
Start: 01/01/1997

M95

Services subjected to Home Health Initiative medical review/cost report audit.
Start: 01/01/1997

M96

The technical component of a service furnished to an inpatient may only be billed by that inpatient facility. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only.
Start: 01/01/1997

M97

Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.
Start: 01/01/1997

M99

Missing/incomplete/invalid Universal Product Number/Serial Number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M100

We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug.
Start: 01/01/1997

M102

Service not performed on equipment approved by the FDA for this purpose.
Start: 01/01/1997

M103

Information supplied supports a break in therapy. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment.
Start: 01/01/1997

M104

Information supplied supports a break in therapy. A new capped rental period will begin with delivery of the equipment. This is the maximum approved under the fee schedule for this item or service.
Start: 01/01/1997

M105

Information supplied does not support a break in therapy. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin.
Start: 01/01/1997

M107

Payment reduced as 90-day rolling average hematocrit for ESRD patient exceeded 36.5%.
Start: 01/01/1997

M109

We have provided you with a bundled payment for a teleconsultation. You must send 25 percent of the teleconsultation payment to the referring practitioner.
Start: 01/01/1997

M111

We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken.
Start: 01/01/1997

M112

Reimbursement for this item is based on the single payment amount required under the DMEPOS Competitive Bidding Program for the area where the patient resides.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)

M113

Our records indicate that this patient began using this item/service prior to the current contract period for the DMEPOS Competitive Bidding Program.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)

M114

This service was processed in accordance with rules and guidelines under the DMEPOS Competitive Bidding Program or a Demonstration Project. For more information regarding these projects, contact your local contractor.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 8/1/06, 11/5/07)

M115

This item is denied when provided to this patient by a non-contract or non-demonstration supplier.
Start: 01/01/1997 | Last Modified: 11/05/2007
Notes: (Modified 11/5/2007)

M116

Paid under the Competitive Bidding Demonstration project. Project is ending, and future services may not be paid under this project.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)

M117

Not covered unless submitted via electronic claim.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

M118

Alert: Letter to follow containing further information.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

M119

Missing/incomplete/invalid/ deactivated/withdrawn National Drug Code (NDC).
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 2/28/03, 4/1/04)

M121

We pay for this service only when performed with a covered cryosurgical ablation.
Start: 01/01/1997

M122

Missing/incomplete/invalid level of subluxation.
Start: 01/01/1997 | Last Modified: 02/28/2006
Notes: (Modified 2/28/03)

M123

Missing/incomplete/invalid name, strength, or dosage of the drug furnished.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M124

Missing indication of whether the patient owns the equipment that requires the part or supply.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N230

M125

Missing/incomplete/invalid information on the period of time for which the service/supply/equipment will be needed.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M126

Missing/incomplete/invalid individual lab codes included in the test.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M127

Missing patient medical record for this service.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N237

M129

Missing/incomplete/invalid indicator of x-ray availability for review.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 2/28/03, 6/30/03)

M130

Missing invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N231

M131

Missing physician financial relationship form.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N239

M132

Missing pacemaker registration form.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N235

M133

Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test.
Start: 01/01/1997

M134

Performed by a facility/supplier in which the provider has a financial interest.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

M135

Missing/incomplete/invalid plan of treatment.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M136

Missing/incomplete/invalid indication that the service was supervised or evaluated by a physician.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

M137

Part B coinsurance under a demonstration project.
Start: 01/01/1997

M138

Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered. Coverage is limited to demonstration participants.
Start: 01/01/1997

M139

Denied services exceed the coverage limit for the demonstration.
Start: 01/01/1997

M141

Missing physician certified plan of care.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N238

M142

Missing American Diabetes Association Certificate of Recognition.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N226

M143

The provider must update license information with the payer.
Start: 01/01/1997 | Last Modified: 12/01/2006
Notes: (Modified 12/1/06)

M144

Pre-/post-operative care payment is included in the allowance for the surgery/procedure.
Start: 01/01/1997

MA01

Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 4/1/07)

MA02

Alert: If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 10/31/02, 6/30/03, 8/1/05, 12/29/05, 8/1/06, 4/1/07)

MA04

Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.
Start: 01/01/1997

MA07

Alert: The claim information has also been forwarded to Medicaid for review.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA08

Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA09

Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims.
Start: 01/01/1997

MA10

Alert: The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA12

You have not established that you have the right under the law to bill for services furnished by the person(s) that furnished this (these) service(s).
Start: 01/01/1997

MA13

Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA14

Alert: The patient is a member of an employer-sponsored prepaid health plan. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time. In the future, we will not pay you for non-plan services.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 4/1/07, 8/1/07)

MA15

Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA16

The patient is covered by the Black Lung Program. Send this claim to the Department of Labor, Federal Black Lung Program, P.O. Box 828, Lanham-Seabrook MD 20703.
Start: 01/01/1997

MA17

We are the primary payer and have paid at the primary rate. You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment.
Start: 01/01/1997

MA18

Alert: The claim information is also being forwarded to the patient's supplemental insurer. Send any questions regarding supplemental benefits to them.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA19

Alert: Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA20

Skilled Nursing Facility (SNF) stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

MA21

SSA records indicate mismatch with name and sex.
Start: 01/01/1997

MA22

Payment of less than $1.00 suppressed.
Start: 01/01/1997

MA23

Demand bill approved as result of medical review.
Start: 01/01/1997

MA24

Christian Science Sanitarium/ Skilled Nursing Facility (SNF) bill in the same benefit period.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

MA25

A patient may not elect to change a hospice provider more than once in a benefit period.
Start: 01/01/1997

MA26

Alert: Our records indicate that you were previously informed of this rule.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA27

Missing/incomplete/invalid entitlement number or name shown on the claim.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA28

Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA30

Missing/incomplete/invalid type of bill.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA31

Missing/incomplete/invalid beginning and ending dates of the period billed.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA32

Missing/incomplete/invalid number of covered days during the billing period.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA33

Missing/incomplete/invalid noncovered days during the billing period.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA34

Missing/incomplete/invalid number of coinsurance days during the billing period.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA35

Missing/incomplete/invalid number of lifetime reserve days.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA36

Missing/incomplete/invalid patient name.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA37

Missing/incomplete/invalid patient's address.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA39

Missing/incomplete/invalid gender.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA40

Missing/incomplete/invalid admission date.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA41

Missing/incomplete/invalid admission type.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA42

Missing/incomplete/invalid admission source.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA43

Missing/incomplete/invalid patient status.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA44

Alert: No appeal rights. Adjudicative decision based on law.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA45

Alert: As previously advised, a portion or all of your payment is being held in a special account.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA46

The new information was considered but additional payment will not be issued.
Start: 01/01/1997 | Last Modified: 03/01/2009
Notes: (Modified 3/1/2009)

MA47

Our records show you have opted out of Medicare, agreeing with the patient not to bill Medicare for services/tests/supplies furnished. As result, we cannot pay this claim. The patient is responsible for payment.
Start: 01/01/1997

MA48

Missing/incomplete/invalid name or address of responsible party or primary payer.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA50

Missing/incomplete/invalid Investigational Device Exemption number for FDA-approved clinical trial services.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA53

Missing/incomplete/invalid Competitive Bidding Demonstration Project identification.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)

MA54

Physician certification or election consent for hospice care not received timely.
Start: 01/01/1997

MA55

Not covered as patient received medical health care services, automatically revoking his/her election to receive religious non-medical health care services.
Start: 01/01/1997

MA56

MA57

Patient submitted written request to revoke his/her election for religious non-medical health care services.
Start: 01/01/1997

MA58

Missing/incomplete/invalid release of information indicator.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA59

Alert: The patient overpaid you for these services. You must issue the patient a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA60

Missing/incomplete/invalid patient relationship to insured.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA61

Missing/incomplete/invalid social security number or health insurance claim number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA62

Alert: This is a telephone review decision.
Start: 01/01/1997 | Last Modified: 08/01/2007
Notes: (Modified 4/1/07, 8/1/07)

MA63

Missing/incomplete/invalid principal diagnosis.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA64

Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.
Start: 01/01/1997

MA65

Missing/incomplete/invalid admitting diagnosis.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA66

Missing/incomplete/invalid principal procedure code.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N303

MA67

Correction to a prior claim.
Start: 01/01/1997

MA68

Alert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA69

Missing/incomplete/invalid remarks.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA70

Missing/incomplete/invalid provider representative signature.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA71

Missing/incomplete/invalid provider representative signature date.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA72

Alert: The patient overpaid you for these assigned services. You must issue the patient a refund within 30 days for the difference between his/her payment to you and the total of the amount shown as patient responsibility and as paid to the patient on this notice.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA73

Informational remittance associated with a Medicare demonstration. No payment issued under fee-for-service Medicare as patient has elected managed care.
Start: 01/01/1997

MA74

This payment replaces an earlier payment for this claim that was either lost, damaged or returned.
Start: 01/01/1997

MA75

Missing/incomplete/invalid patient or authorized representative signature.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA76

Missing/incomplete/invalid provider identifier for home health agency or hospice when physician is performing care plan oversight services.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03, 2/1/04)

MA77

Alert: The patient overpaid you. You must issue the patient a refund within 30 days for the difference between the patient's payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice.
Start: 01/01/1997 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

MA79

Billed in excess of interim rate.
Start: 01/01/1997

MA80

Informational notice. No payment issued for this claim with this notice. Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project.
Start: 01/01/1997

MA81

Missing/incomplete/invalid provider/supplier signature.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA83

Did not indicate whether we are the primary or secondary payer.
Start: 01/01/1997 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05)

MA84

Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy.
Start: 01/01/1997

MA88

Missing/incomplete/invalid insured's address and/or telephone number for the primary payer.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA89

Missing/incomplete/invalid patient's relationship to the insured for the primary payer.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA90

Missing/incomplete/invalid employment status code for the primary insured.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03).

MA91

This determination is the result of the appeal you filed.
Start: 01/01/1997

MA92

Missing plan information for other insurance.
Start: 01/01/1997 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04) Related to N245

MA93

Non-PIP (Periodic Interim Payment) claim.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

MA94

Did not enter the statement "Attending physician not hospice employee" on the claim form to certify that the rendering physician is not an employee of the hospice.
Start: 01/01/1997 | Last Modified: 08/01/2005
Notes: (Reactivated 4/1/04, Modified 8/1/05)

MA96

Claim rejected. Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan.
Start: 01/01/1997

MA97

Missing/incomplete/invalid Medicare Managed Care Demonstration contract number or clinical trial registry number.
Start: 01/01/1997 | Last Modified: 02/29/2008
Notes: (Modified 2/29/08)

MA99

Missing/incomplete/invalid Medigap information.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA100

Missing/incomplete/invalid date of current illness or symptoms
Start: 01/01/1997 | Last Modified: 03/30/2005
Notes: (Modified 2/28/03, 3/30/05)

MA101

A Skilled Nursing Facility (SNF) is responsible for payment of outside providers who furnish these services/supplies to residents.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

MA103

Hemophilia Add On.
Start: 01/01/1997

MA106

PIP (Periodic Interim Payment) claim.
Start: 01/01/1997 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

MA107

Paper claim contains more than three separate data items in field 19.
Start: 01/01/1997

MA108

Paper claim contains more than one data item in field 23.
Start: 01/01/1997

MA109

Claim processed in accordance with ambulatory surgical guidelines.
Start: 01/01/1997

MA110

Missing/incomplete/invalid information on whether the diagnostic test(s) were performed by an outside entity or if no purchased tests are included on the claim.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA111

Missing/incomplete/invalid purchase price of the test(s) and/or the performing laboratory's name and address.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA112

Missing/incomplete/invalid group practice information.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA113

Incomplete/invalid taxpayer identification number (TIN) submitted by you per the Internal Revenue Service. Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN.
Start: 01/01/1997

MA114

Missing/incomplete/invalid information on where the services were furnished.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA115

Missing/incomplete/invalid physical location (name and address, or PIN) where the service(s) were rendered in a Health Professional Shortage Area (HPSA).
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA116

Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution.
Start: 01/01/1997
Notes: (Reactivated 4/1/04)

MA117

This claim has been assessed a $1.00 user fee.
Start: 01/01/1997

MA118

Coinsurance and/or deductible amounts apply to a claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. No Medicare payment issued.
Start: 01/01/1997

MA120

Missing/incomplete/invalid CLIA certification number.
Start: 01/01/1997 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

MA121

Missing/incomplete/invalid x-ray date.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)

MA122

Missing/incomplete/invalid initial treatment date.
Start: 01/01/1997 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)

MA123

Your center was not selected to participate in this study, therefore, we cannot pay for these services.
Start: 01/01/1997

MA125

Per legislation governing this program, payment constitutes payment in full.
Start: 01/01/1997

MA126

Pancreas transplant not covered unless kidney transplant performed.
Start: 10/12/2001

MA128

Missing/incomplete/invalid FDA approval number.
Start: 10/12/2001 | Last Modified: 03/30/2005
Notes: (Modified 2/28/03, 3/30/05)

MA130

Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.
Start: 10/12/2001

MA131

Physician already paid for services in conjunction with this demonstration claim. You must have the physician withdraw that claim and refund the payment before we can process your claim.
Start: 10/12/2001

MA132

Adjustment to the pre-demonstration rate.
Start: 10/12/2001

MA133

Claim overlaps inpatient stay. Rebill only those services rendered outside the inpatient stay.
Start: 10/12/2001

MA134

Missing/incomplete/invalid provider number of the facility where the patient resides.
Start: 10/12/2001

Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 2/28/03, 4/1/07)

This allowance has been made in accordance with the most appropriate course of treatment provision of the plan.
Start: 01/01/2000

Missing consent form.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03) Related to N228

Missing/incomplete/invalid prior insurance carrier EOB.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

EOB received from previous payer. Claim not on file.
Start: 01/01/2000

Under FEHB law (U.S.C. 8904(b)), we cannot pay more for covered care than the amount Medicare would have allowed if the patient were enrolled in Medicare Part A and/or Medicare Part B.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

Processing of this claim/service has included consideration under Major Medical provisions.
Start: 01/01/2000

Crossover claim denied by previous payer and complete claim data not forwarded. Resubmit this claim to this payer to provide adequate data for adjudication.
Start: 01/01/2000

Adjustment represents the estimated amount a previous payer may pay.
Start: 01/01/2000 | Last Modified: 11/18/2005
Notes: (Modified 11/18/05)

N10

Payment based on the findings of a review organization/professional consult/manual adjudication/medical or dental advisor.
Start: 01/01/2000 | Last Modified: 07/01/2008
Notes: (Modified 10/31/02, 7/1/08)

N11

Denial reversed because of medical review.
Start: 01/01/2000

N12

Policy provides coverage supplemental to Medicare. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.
Start: 01/01/2000 | Last Modified: 08/01/2007
Notes: (Modified 8/1/07)

N13

Payment based on professional/technical component modifier(s).
Start: 01/01/2000

N15

Services for a newborn must be billed separately.
Start: 01/01/2000

N16

Family/member Out-of-Pocket maximum has been met. Payment based on a higher percentage.
Start: 01/01/2000

N19

Procedure code incidental to primary procedure.
Start: 01/01/2000

N20

Service not payable with other service rendered on the same date.
Start: 01/01/2000

N21

Alert: Your line item has been separated into multiple lines to expedite handling.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 8/1/05, 4/1/07)

N22

This procedure code was added/changed because it more accurately describes the services rendered.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 10/31/02, 2/28/03)

N23

Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 8/13/01, 4/1/07)

N24

Missing/incomplete/invalid Electronic Funds Transfer (EFT) banking information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N25

This company has been contracted by your benefit plan to provide administrative claims payment services only. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan.
Start: 01/01/2000

N26

Missing itemized bill/statement.
Start: 01/01/2000 | Last Modified: 07/01/2008
Notes: (Modified 2/28/03, 7/1/2008) Related to N232

N27

Missing/incomplete/invalid treatment number.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N28

Consent form requirements not fulfilled.
Start: 01/01/2000

N29

Missing documentation/orders/notes/summary/report/chart.
Start: 01/01/2000 | Last Modified: 08/01/2005
Notes: (Modified 2/28/03, 8/1/05) Related to N225

N30

Patient ineligible for this service.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N31

Missing/incomplete/invalid prescribing provider identifier.
Start: 01/01/2000 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04)

N32

Claim must be submitted by the provider who rendered the service.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N33

No record of health check prior to initiation of treatment.
Start: 01/01/2000

N34

Incorrect claim form/format for this service.
Start: 01/01/2000 | Last Modified: 11/18/2005
Notes: (Modified 11/18/05)

N35

Program integrity/utilization review decision.
Start: 01/01/2000

N36

Claim must meet primary payer's processing requirements before we can consider payment.
Start: 01/01/2000

N37

Missing/incomplete/invalid tooth number/letter.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N39

Procedure code is not compatible with tooth number/letter.
Start: 01/01/2000

N40

Missing radiology film(s)/image(s).
Start: 01/01/2000 | Last Modified: 07/01/2008
Notes: (Modified 2/1/04, 7/1/08) Related to N242

N42

No record of mental health assessment.
Start: 01/01/2000

N43

Bed hold or leave days exceeded.
Start: 01/01/2000

N45

Payment based on authorized amount.
Start: 01/01/2000

N46

Missing/incomplete/invalid admission hour.
Start: 01/01/2000

N47

Claim conflicts with another inpatient stay.
Start: 01/01/2000

N48

Claim information does not agree with information received from other insurance carrier.
Start: 01/01/2000

N49

Court ordered coverage information needs validation.
Start: 01/01/2000

N50

Missing/incomplete/invalid discharge information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N51

Electronic interchange agreement not on file for provider/submitter.
Start: 01/01/2000

N52

Patient not enrolled in the billing provider's managed care plan on the date of service.
Start: 01/01/2000

N53

Missing/incomplete/invalid point of pick-up address.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N54

Claim information is inconsistent with pre-certified/authorized services.
Start: 01/01/2000

N55

Procedures for billing with group/referring/performing providers were not followed.
Start: 01/01/2000

N56

Procedure code billed is not correct/valid for the services billed or the date of service billed.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N57

Missing/incomplete/invalid prescribing date.
Start: 01/01/2000 | Last Modified: 12/02/2004
Notes: (Modified 12/2/04) Related to N304

N58

Missing/incomplete/invalid patient liability amount.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N59

Alert: Please refer to your provider manual for additional program and provider information.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N61

Rebill services on separate claims.
Start: 01/01/2000

N62

Inpatient admission spans multiple rate periods. Resubmit separate claims.
Start: 01/01/2000

N63

Rebill services on separate claim lines.
Start: 01/01/2000

N64

The "from" and "to" dates must be different.
Start: 01/01/2000

N65

Procedure code or procedure rate count cannot be determined, or was not on file, for the date of service/provider.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N67

Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient's admission or discharge from a demonstration hospital. If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.
Start: 01/01/2000

N68

Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days.
Start: 01/01/2000

N69

PPS (Prospective Payment System) code changed by claims processing system. Insufficient visits or therapies.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N70

Consolidated billing and payment applies.
Start: 01/01/2000 | Last Modified: 11/05/2007
Notes: (Modified 2/28/02, 11/5/07)

N71

Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim. You are required by law to accept assignment for these types of claims.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 2/21/02, 6/30/03)

N72

PPS (Prospective Payment System) code changed by medical reviewers. Not supported by clinical records.
Start: 01/01/2000 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N74

Resubmit with multiple claims, each claim covering services provided in only one calendar month.
Start: 01/01/2000

N75

Missing/incomplete/invalid tooth surface information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N76

Missing/incomplete/invalid number of riders.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N77

Missing/incomplete/invalid designated provider number.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N78

The necessary components of the child and teen checkup (EPSDT) were not completed.
Start: 01/01/2000

N79

Service billed is not compatible with patient location information.
Start: 01/01/2000

N80

Missing/incomplete/invalid prenatal screening information.
Start: 01/01/2000 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N81

Procedure billed is not compatible with tooth surface code.
Start: 01/01/2000

N82

Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement.
Start: 01/01/2000

N83

No appeal rights. Adjudicative decision based on the provisions of a demonstration project.
Start: 01/01/2000

N84

Alert: Further installment payments are forthcoming.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07, 8/1/07)

N85

Alert: This is the final installment payment.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07, 8/1/07)

N86

A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered.
Start: 01/01/2000

N87

Home use of biofeedback therapy is not covered.
Start: 01/01/2000

N88

Alert: This payment is being made conditionally. An HHA episode of care notice has been filed for this patient. When a patient is treated under a HHA episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the HHA's payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of care.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N89

Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.
Start: 01/01/2000 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N90

Covered only when performed by the attending physician.
Start: 01/01/2000

N91

Services not included in the appeal review.
Start: 01/01/2000

N92

This facility is not certified for digital mammography.
Start: 01/01/2000

N93

A separate claim must be submitted for each place of service. Services furnished at multiple sites may not be billed in the same claim.
Start: 01/01/2000

N94

Claim/Service denied because a more specific taxonomy code is required for adjudication.
Start: 01/01/2000

N95

This provider type/provider specialty may not bill this service.
Start: 07/31/2001 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N96

Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.
Start: 08/24/2001

N97

Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded.
Start: 08/24/2001

N98

Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50 percent or greater improvement through test stimulation. Improvement is measured through voiding diaries.
Start: 08/24/2001

N99

Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.
Start: 08/24/2001

N100

PPS (Prospect Payment System) code corrected during adjudication.
Start: 09/14/2001 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N102

This claim has been denied without reviewing the medical record because the requested records were not received or were not received timely.
Start: 10/31/2001

N103

Social Security records indicate that this patient was a prisoner when the service was rendered. This payer does not cover items and services furnished to an individual while they are in State or local custody under a penal authority, unless under State or local law, the individual is personally liable for the cost of his or her health care while incarcerated and the State or local government pursues such debt in the same way and with the same vigor as any other debt.
Start: 10/31/2001 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N104

This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.hhs.gov.
Start: 01/29/2002 | Last Modified: 10/31/2002
Notes: (Modified 10/31/02)

N105

This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 866-749-4301 for RRB EDI information for electronic claims processing.
Start: 01/29/2002

N106

Payment for services furnished to Skilled Nursing Facility (SNF) inpatients (except for excluded services) can only be made to the SNF. You must request payment from the SNF rather than the patient for this service.
Start: 01/31/2002

N107

Services furnished to Skilled Nursing Facility (SNF) inpatients must be billed on the inpatient claim. They cannot be billed separately as outpatient services.
Start: 01/31/2002

N108

Missing/incomplete/invalid upgrade information.
Start: 01/31/2002 | Last Modified: 02/28/2003
Notes: (Modified 2/28/03)

N109

This claim/service was chosen for complex review and was denied after reviewing the medical records.
Start: 02/28/2002 | Last Modified: 03/01/2009
Notes: (Modified 3/1/2009)

N110

This facility is not certified for film mammography.
Start: 02/28/2002

N111

No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated.
Start: 02/28/2002

N112

This claim is excluded from your electronic remittance advice.
Start: 02/28/2002

N113

Only one initial visit is covered per physician, group practice or provider.
Start: 04/16/2002 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N114

During the transition to the Ambulance Fee Schedule, payment is based on the lesser of a blended amount calculated using a percentage of the reasonable charge/cost and fee schedule amounts, or the submitted charge for the service. You will be notified yearly what the percentages for the blended payment calculation will be.
Start: 05/30/2002

N115

This decision was based on a local medical review policy (LMRP) or Local Coverage Determination (LCD).An LMRP/LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LMRP/LCD.
Start: 05/30/2002 | Last Modified: 04/01/2004
Notes: (Modified 4/1/04)

N116

This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency's (HHA's) payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care.
Start: 06/30/2002

N117

This service is paid only once in a patient's lifetime.
Start: 07/30/2002 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N118

This service is not paid if billed more than once every 28 days.
Start: 07/30/2002

N119

This service is not paid if billed once every 28 days, and the patient has spent 5 or more consecutive days in any inpatient or Skilled /nursing Facility (SNF) within those 28 days.
Start: 07/30/2002 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N120

Payment is subject to home health prospective payment system partial episode payment adjustment. Patient was transferred/discharged/readmitted during payment episode.
Start: 08/09/2002 | Last Modified: 06/30/2003
Notes: (Modified 6/30/03)

N121

Medicare Part B does not pay for items or services provided by this type of practitioner for beneficiaries in a Medicare Part A covered Skilled Nursing Facility (SNF) stay.
Start: 09/09/2002 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04, 6/30/03)

N122

Add-on code cannot be billed by itself.
Start: 09/12/2002 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05)

N123

This is a split service and represents a portion of the units from the originally submitted service.
Start: 09/24/2002

N124

Payment has been denied for the/made only for a less extensive service/item because the information furnished does not substantiate the need for the (more extensive) service/item. The patient is liable for the charges for this service/item as you informed the patient in writing before the service/item was furnished that we would not pay for it, and the patient agreed to pay.
Start: 09/26/2002

N125

Payment has been (denied for the/made only for a less extensive) service/item because the information furnished does not substantiate the need for the (more extensive) service/item. If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice.

The requirements for a refund are in 1834(a)(18) of the Social Security Act (and in 1834(j)(4) and 1879(h) by cross-reference to 1834(a)(18)). Section 1834(a)(18)(B) specifies that suppliers which knowingly and willfully fail to make appropriate refunds may be subject to civil money penalties and/or exclusion from the Medicare program. If you have any questions about this notice, please contact this office.
Start: 09/26/2002 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05. Also refer to N356)

N126

Social Security Records indicate that this individual has been deported. This payer does not cover items and services furnished to individuals who have been deported.
Start: 10/17/2002

N127

This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.
Start: 10/31/2007 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04

N128

This amount represents the prior to coverage portion of the allowance.
Start: 10/31/2002

N129

Not eligible due to the patient's age.
Start: 10/31/2002 | Last Modified: 08/01/2007
Notes: (Modified 8/1/07)

N130

Alert: Consult plan benefit documents/guidelines for information about restrictions for this service.
Start: 10/31/2002 | Last Modified: 07/01/2008
Notes: (Modified 4/1/07, 7/1/08)

N131

Total payments under multiple contracts cannot exceed the allowance for this service.
Start: 10/31/2002

N132

Alert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N133

Alert: Services for predetermination and services requesting payment are being processed separately.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N134

Alert: This represents your scheduled payment for this service. If treatment has been discontinued, please contact Customer Service.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N135

Record fees are the patient's responsibility and limited to the specified co-payment.
Start: 10/31/2002

N136

Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at (602) 912-8444 or (800) 325-2548.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N137

Alert: The provider acting on the Member's behalf, may file an appeal with the Payer. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered. The address may be obtained from the State Insurance Regulatory Authority.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 8/1/04, 2/28/03, 4/1/07)

N138

Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance carrier for a second Independent Dental Advisor Review.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N139

Alert: Under the Code of Federal Regulations, Chapter 32, Section 199.13 a non-participating provider is not an appropriate appealing party. Therefore, if you disagree with the Dental Advisor's opinion, you may appeal the determination if appointed in writing, by the beneficiary, to act as his/her representative. Should you be appointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N140

Alert: You have not been designated as an authorized OCONUS provider therefore are not considered an appropriate appealing party. If the beneficiary has appointed you, in writing, to act as his/her representative and you disagree with the Dental Advisor's opinion, you may appeal by submitting a copy of this letter, a signed statement explaining the matter in which you disagree, and any relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N141

The patient was not residing in a long-term care facility during all or part of the service dates billed.
Start: 10/31/2002

N142

The original claim was denied. Resubmit a new claim, not a replacement claim.
Start: 10/31/2002

N143

The patient was not in a hospice program during all or part of the service dates billed.
Start: 10/31/2002

N144

The rate changed during the dates of service billed.
Start: 10/31/2002

N146

Missing screening document.
Start: 10/31/2002 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04) Related to N243

N147

Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.
Start: 10/31/2002

N148

Missing/incomplete/invalid date of last menstrual period.
Start: 10/31/2002

N149

Rebill all applicable services on a single claim.
Start: 10/31/2002

N150

Missing/incomplete/invalid model number.
Start: 10/31/2002

N151

Telephone contact services will not be paid until the face-to-face contact requirement has been met.
Start: 10/31/2002

N152

Missing/incomplete/invalid replacement claim information.
Start: 10/31/2002

N153

Missing/incomplete/invalid room and board rate.
Start: 10/31/2002

N154

Alert: This payment was delayed for correction of provider's mailing address.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N155

Alert: Our records do not indicate that other insurance is on file. Please submit other insurance information for our records.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N156

Alert: The patient is responsible for the difference between the approved treatment and the elective treatment.
Start: 10/31/2002 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N157

Transportation to/from this destination is not covered.
Start: 02/28/2003 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)

N158

Transportation in a vehicle other than an ambulance is not covered.
Start: 02/28/2003

N159

Payment denied/reduced because mileage is not covered when the patient is not in the ambulance.
Start: 02/28/2003

N160

The patient must choose an option before a payment can be made for this procedure/ equipment/ supply/ service.
Start: 02/28/2003 | Last Modified: 02/01/2004
Notes: (Modified 2/1/04)

N161

This drug/service/supply is covered only when the associated service is covered.
Start: 02/28/2003

N162

Alert: Although your claim was paid, you have billed for a test/specialty not included in your Laboratory Certification. Your failure to correct the laboratory certification information will result in a denial of payment in the near future.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N163

Medical record does not support code billed per the code definition.
Start: 02/28/2003

N167

Charges exceed the post-transplant coverage limit.
Start: 02/28/2003

N170

A new/revised/renewed certificate of medical necessity is needed.
Start: 02/28/2003

N171

Payment for repair or replacement is not covered or has exceeded the purchase price.
Start: 02/28/2003

N172

The patient is not liable for the denied/adjusted charge(s) for receiving any updated service/item.
Start: 02/28/2003

N173

No qualifying hospital stay dates were provided for this episode of care.
Start: 02/28/2003

N174

This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group 'PR'.
Start: 02/28/2003

N175

Missing review organization approval.
Start: 02/28/2003 | Last Modified: 02/29/2008
Notes: (Modified 8/1/04, 2/29/08) Related to N241

N176

Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters. In addition, a doctor licensed to practice in the United States must provide the service.
Start: 02/28/2003

N177

Alert: We did not send this claim to patient's other insurer. They have indicated no additional payment can be made.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 6/30/03, 4/1/07)

N178

Missing pre-operative photos or visual field results.
Start: 02/28/2003 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04) Related to N244

N179

Additional information has been requested from the member. The charges will be reconsidered upon receipt of that information.
Start: 02/28/2003

N180

This item or service does not meet the criteria for the category under which it was billed.
Start: 02/28/2003

N181

Additional information is required from another provider involved in this service.
Start: 02/28/2003 | Last Modified: 12/01/2006
Notes: (Modified 12/1/06)

N182

This claim/service must be billed according to the schedule for this plan.
Start: 02/28/2003

N183

Alert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N184

Rebill technical and professional components separately.
Start: 02/28/2003

N185

Alert: Do not resubmit this claim/service.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N186

Non-Availability Statement (NAS) required for this service. Contact the nearest Military Treatment Facility (MTF) for assistance.
Start: 02/28/2003

N187

Alert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N188

The approved level of care does not match the procedure code submitted.
Start: 02/28/2003

N189

Alert: This service has been paid as a one-time exception to the plan's benefit restrictions.
Start: 02/28/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N190

Missing contract indicator.
Start: 02/28/2003 | Last Modified: 08/01/2004
Notes: (Modified 8/1/04) Related to N229

N191

The provider must update insurance information directly with payer.
Start: 02/28/2003

N192

Patient is a Medicaid/Qualified Medicare Beneficiary.
Start: 02/28/2003

N193

Specific federal/state/local program may cover this service through another payer.
Start: 02/28/2003

N194

Technical component not paid if provider does not own the equipment used.
Start: 02/25/2003

N195

The technical component must be billed separately.
Start: 02/25/2003

N196

Alert: Patient eligible to apply for other coverage which may be primary.
Start: 02/25/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N197

The subscriber must update insurance information directly with payer.
Start: 02/25/2003

N198

Rendering provider must be affiliated with the pay-to provider.
Start: 02/25/2003

N199

Additional payment/recoupment approved based on payer-initiated review/audit.
Start: 02/25/2003 | Last Modified: 08/01/2006
Notes: (Modified 8/1/06)

N200

The professional component must be billed separately.
Start: 02/25/2003

N201

A mental health facility is responsible for payment of outside providers who furnish these services/supplies to residents.
Start: 02/25/2003

N202

Alert: Additional information/explanation will be sent separately
Start: 06/30/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N203

Missing/incomplete/invalid anesthesia time/units
Start: 06/30/2003

N204

Services under review for possible pre-existing condition. Send medical records for prior 12 months
Start: 06/30/2003

N205

Information provided was illegible
Start: 06/30/2003

N206

The supporting documentation does not match the claim
Start: 06/30/2003

N207

Missing/incomplete/invalid weight.
Start: 06/30/2003 | Last Modified: 11/18/2005
Notes: (Modified 11/18/05)

N208

Missing/incomplete/invalid DRG code
Start: 06/30/2003

N209

Missing/incomplete/invalid taxpayer identification number (TIN).
Start: 06/30/2003 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N210

Alert: You may appeal this decision
Start: 06/30/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N211

Alert: You may not appeal this decision
Start: 06/30/2003 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N212

Charges processed under a Point of Service benefit
Start: 02/01/2004

N213

Missing/incomplete/invalid facility/discrete unit DRG/DRG exempt status information
Start: 04/01/2004

N214

Missing/incomplete/invalid history of the related initial surgical procedure(s)
Start: 04/01/2004

N215

Alert: A payer providing supplemental or secondary coverage shall not require a claims determination for this service from a primary payer as a condition of making its own claims determination.
Start: 04/01/2004 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N216

Patient is not enrolled in this portion of our benefit package
Start: 04/01/2004

N217

We pay only one site of service per provider per claim
Start: 08/01/2004

N218

You must furnish and service this item for as long as the patient continues to need it. We can pay for maintenance and/or servicing for the time period specified in the contract or coverage manual.
Start: 08/01/2004

N219

Payment based on previous payer's allowed amount.
Start: 08/01/2004

N220

Alert: See the payer's web site or contact the payer's Customer Service department to obtain forms and instructions for filing a provider dispute.
Start: 08/01/2004 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N221

Missing Admitting History and Physical report.
Start: 08/01/2004

N222

Incomplete/invalid Admitting History and Physical report.
Start: 08/01/2004

N223

Missing documentation of benefit to the patient during initial treatment period.
Start: 08/01/2004

N224

Incomplete/invalid documentation of benefit to the patient during initial treatment period.
Start: 08/01/2004

N225

Incomplete/invalid documentation/orders/notes/summary/report/chart.
Start: 08/01/2004 | Last Modified: 08/01/2005
Notes: (Modified 8/1/05)

N226

Incomplete/invalid American Diabetes Association Certificate of Recognition.
Start: 08/01/2004

N227

Incomplete/invalid Certificate of Medical Necessity.
Start: 08/01/2004

N228

Incomplete/invalid consent form.
Start: 08/01/2004

N229

Incomplete/invalid contract indicator.
Start: 08/01/2004

N230

Incomplete/invalid indication of whether the patient owns the equipment that requires the part or supply.
Start: 08/01/2004

N231

Incomplete/invalid invoice or statement certifying the actual cost of the lens, less discounts, and/or the type of intraocular lens used.
Start: 08/01/2004

N232

Incomplete/invalid itemized bill/statement.
Start: 08/01/2004 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N233

Incomplete/invalid operative note/report.
Start: 08/01/2004 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N234

Incomplete/invalid oxygen certification/re-certification.
Start: 08/01/2004

N235

Incomplete/invalid pacemaker registration form.
Start: 08/01/2004

N236

Incomplete/invalid pathology report.
Start: 08/01/2004

N237

Incomplete/invalid patient medical record for this service.
Start: 08/01/2004

N238

Incomplete/invalid physician certified plan of care
Start: 08/01/2004

N239

Incomplete/invalid physician financial relationship form.
Start: 08/01/2004

N240

Incomplete/invalid radiology report.
Start: 08/01/2004

N241

Incomplete/invalid review organization approval.
Start: 08/01/2004 | Last Modified: 02/29/2008
Notes: (Modified 2/29/08)

N242

Incomplete/invalid radiology film(s)/image(s).
Start: 08/01/2004 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N243

Incomplete/invalid/not approved screening document.
Start: 08/01/2004

N244

Incomplete/invalid pre-operative photos/visual field results.
Start: 08/01/2004

N245

Incomplete/invalid plan information for other insurance
Start: 08/01/2004

N246

State regulated patient payment limitations apply to this service.
Start: 12/02/2004

N247

Missing/incomplete/invalid assistant surgeon taxonomy.
Start: 12/02/2004

N248

Missing/incomplete/invalid assistant surgeon name.
Start: 12/02/2004

N249

Missing/incomplete/invalid assistant surgeon primary identifier.
Start: 12/02/2004

N250

Missing/incomplete/invalid assistant surgeon secondary identifier.
Start: 12/02/2004

N251

Missing/incomplete/invalid attending provider taxonomy.
Start: 12/02/2004

N252

Missing/incomplete/invalid attending provider name.
Start: 12/02/2004

N253

Missing/incomplete/invalid attending provider primary identifier.
Start: 12/02/2004

N254

Missing/incomplete/invalid attending provider secondary identifier.
Start: 12/02/2004

N255

Missing/incomplete/invalid billing provider taxonomy.
Start: 12/02/2004

N256

Missing/incomplete/invalid billing provider/supplier name.
Start: 12/02/2004

N257

Missing/incomplete/invalid billing provider/supplier primary identifier.
Start: 12/02/2004

N258

Missing/incomplete/invalid billing provider/supplier address.
Start: 12/02/2004

N259

Missing/incomplete/invalid billing provider/supplier secondary identifier.
Start: 12/02/2004

N260

Missing/incomplete/invalid billing provider/supplier contact information.
Start: 12/02/2004

N261

Missing/incomplete/invalid operating provider name.
Start: 12/02/2004

N262

Missing/incomplete/invalid operating provider primary identifier.
Start: 12/02/2004

N263

Missing/incomplete/invalid operating provider secondary identifier.
Start: 12/02/2004

N264

Missing/incomplete/invalid ordering provider name.
Start: 12/02/2004

N265

Missing/incomplete/invalid ordering provider primary identifier.
Start: 12/02/2004

N266

Missing/incomplete/invalid ordering provider address.
Start: 12/02/2004

N267

Missing/incomplete/invalid ordering provider secondary identifier.
Start: 12/02/2004

N268

Missing/incomplete/invalid ordering provider contact information.
Start: 12/02/2004

N269

Missing/incomplete/invalid other provider name.
Start: 12/02/2004

N270

Missing/incomplete/invalid other provider primary identifier.
Start: 12/02/2004

N271

Missing/incomplete/invalid other provider secondary identifier.
Start: 12/02/2004

N272

Missing/incomplete/invalid other payer attending provider identifier.
Start: 12/02/2004

N273

Missing/incomplete/invalid other payer operating provider identifier.
Start: 12/02/2004

N274

Missing/incomplete/invalid other payer other provider identifier.
Start: 12/02/2004

N275

Missing/incomplete/invalid other payer purchased service provider identifier.
Start: 12/02/2004

N276

Missing/incomplete/invalid other payer referring provider identifier.
Start: 12/02/2004

N277

Missing/incomplete/invalid other payer rendering provider identifier.
Start: 12/02/2004

N278

Missing/incomplete/invalid other payer service facility provider identifier.
Start: 12/02/2004

N279

Missing/incomplete/invalid pay-to provider name.
Start: 12/02/2004

N280

Missing/incomplete/invalid pay-to provider primary identifier.
Start: 12/02/2004

N281

Missing/incomplete/invalid pay-to provider address.
Start: 12/02/2004

N282

Missing/incomplete/invalid pay-to provider secondary identifier.
Start: 12/02/2004

N283

Missing/incomplete/invalid purchased service provider identifier.
Start: 12/02/2004

N284

Missing/incomplete/invalid referring provider taxonomy.
Start: 12/02/2004

N285

Missing/incomplete/invalid referring provider name.
Start: 12/02/2004

N286

Missing/incomplete/invalid referring provider primary identifier.
Start: 12/02/2004

N287

Missing/incomplete/invalid referring provider secondary identifier.
Start: 12/02/2004

N288

Missing/incomplete/invalid rendering provider taxonomy.
Start: 12/02/2004

N289

Missing/incomplete/invalid rendering provider name.
Start: 12/02/2004

N290

Missing/incomplete/invalid rendering provider primary identifier.
Start: 12/02/2004

N291

Missing/incomplete/invalid rending provider secondary identifier.
Start: 12/02/2004

N292

Missing/incomplete/invalid service facility name.
Start: 12/02/2004

N293

Missing/incomplete/invalid service facility primary identifier.
Start: 12/02/2004

N294

Missing/incomplete/invalid service facility primary address.
Start: 12/02/2004

N295

Missing/incomplete/invalid service facility secondary identifier.
Start: 12/02/2004

N296

Missing/incomplete/invalid supervising provider name.
Start: 12/02/2004

N297

Missing/incomplete/invalid supervising provider primary identifier.
Start: 12/02/2004

N298

Missing/incomplete/invalid supervising provider secondary identifier.
Start: 12/02/2004

N299

Missing/incomplete/invalid occurrence date(s).
Start: 12/02/2004

N300

Missing/incomplete/invalid occurrence span date(s).
Start: 12/02/2004

N301

Missing/incomplete/invalid procedure date(s).
Start: 12/02/2004

N302

Missing/incomplete/invalid other procedure date(s).
Start: 12/02/2004

N303

Missing/incomplete/invalid principal procedure date.
Start: 12/02/2004

N304

Missing/incomplete/invalid dispensed date.
Start: 12/02/2004

N305

Missing/incomplete/invalid accident date.
Start: 12/02/2004

N306

Missing/incomplete/invalid acute manifestation date.
Start: 12/02/2004

N307

Missing/incomplete/invalid adjudication or payment date.
Start: 12/02/2004

N308

Missing/incomplete/invalid appliance placement date.
Start: 12/02/2004

N309

Missing/incomplete/invalid assessment date.
Start: 12/02/2004

N310

Missing/incomplete/invalid assumed or relinquished care date.
Start: 12/02/2004

N311

Missing/incomplete/invalid authorized to return to work date.
Start: 12/02/2004

N312

Missing/incomplete/invalid begin therapy date.
Start: 12/02/2004

N313

Missing/incomplete/invalid certification revision date.
Start: 12/02/2004

N314

Missing/incomplete/invalid diagnosis date.
Start: 12/02/2004

N315

Missing/incomplete/invalid disability from date.
Start: 12/02/2004

N316

Missing/incomplete/invalid disability to date.
Start: 12/02/2004

N317

Missing/incomplete/invalid discharge hour.
Start: 12/02/2004

N318

Missing/incomplete/invalid discharge or end of care date.
Start: 12/02/2004

N319

Missing/incomplete/invalid hearing or vision prescription date.
Start: 12/02/2004

N320

Missing/incomplete/invalid Home Health Certification Period.
Start: 12/02/2004

N321

Missing/incomplete/invalid last admission period.
Start: 12/02/2004

N322

Missing/incomplete/invalid last certification date.
Start: 12/02/2004

N323

Missing/incomplete/invalid last contact date.
Start: 12/02/2004

N324

Missing/incomplete/invalid last seen/visit date.
Start: 12/02/2004

N325

Missing/incomplete/invalid last worked date.
Start: 12/02/2004

N326

Missing/incomplete/invalid last x-ray date.
Start: 12/02/2004

N327

Missing/incomplete/invalid other insured birth date.
Start: 12/02/2004

N328

Missing/incomplete/invalid Oxygen Saturation Test date.
Start: 12/02/2004

N329

Missing/incomplete/invalid patient birth date.
Start: 12/02/2004

N330

Missing/incomplete/invalid patient death date.
Start: 12/02/2004

N331

Missing/incomplete/invalid physician order date.
Start: 12/02/2004

N332

Missing/incomplete/invalid prior hospital discharge date.
Start: 12/02/2004

N333

Missing/incomplete/invalid prior placement date.
Start: 12/02/2004

N334

Missing/incomplete/invalid re-evaluation date
Start: 12/02/2004

N335

Missing/incomplete/invalid referral date.
Start: 12/02/2004

N336

Missing/incomplete/invalid replacement date.
Start: 12/02/2004

N337

Missing/incomplete/invalid secondary diagnosis date.
Start: 12/02/2004

N338

Missing/incomplete/invalid shipped date.
Start: 12/02/2004

N339

Missing/incomplete/invalid similar illness or symptom date.
Start: 12/02/2004

N340

Missing/incomplete/invalid subscriber birth date.
Start: 12/02/2004

N341

Missing/incomplete/invalid surgery date.
Start: 12/02/2004

N342

Missing/incomplete/invalid test performed date.
Start: 12/02/2004

N343

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial start date.
Start: 12/02/2004

N344

Missing/incomplete/invalid Transcutaneous Electrical Nerve Stimulator (TENS) trial end date.
Start: 12/02/2004

N345

Date range not valid with units submitted.
Start: 03/30/2005

N346

Missing/incomplete/invalid oral cavity designation code.
Start: 03/30/2005

N347

Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.
Start: 03/30/2005

N348

You chose that this service/supply/drug would be rendered/supplied and billed by a different practitioner/supplier.
Start: 08/01/2005

N349

The administration method and drug must be reported to adjudicate this service.
Start: 08/01/2005

N350

Missing/incomplete/invalid description of service for a Not Otherwise Classified (NOC) code or for an Unlisted/By Report procedure.
Start: 08/01/2005 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N351

Service date outside of the approved treatment plan service dates.
Start: 08/01/2005

N352

Alert: There are no scheduled payments for this service. Submit a claim for each patient visit.
Start: 08/01/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N353

Alert: Benefits have been estimated, when the actual services have been rendered, additional payment will be considered based on the submitted claim.
Start: 08/01/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N354

Incomplete/invalid invoice
Start: 08/01/2005

N355

Alert: The law permits exceptions to the refund requirement in two cases: - If you did not know, and could not have reasonably been expected to know, that we would not pay for this service; or - If you notified the patient in writing before providing the service that you believed that we were likely to deny the service, and the patient signed a statement agreeing to pay for the service.

If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request appeal of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position.

If you request an appeal within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review. If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision.

The law also permits you to request an appeal at any time within 120 days of the date you receive this notice. However, an appeal request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination.

The patient has received a separate notice of this denial decision. The notice advises that he/she may be entitled to a refund of any amounts paid, if you should have known that we would not pay and did not tell him/her. It also instructs the patient to contact our office if he/she does not hear anything about a refund within 30 days
Start: 08/01/2005 | Last Modified: 04/01/2007
Notes: (Modified 11/18/05, Modified 4/1/07)

N356

This service is not covered when performed with, or subsequent to, a non-covered service.
Start: 08/01/2005

N357

Time frame requirements between this service/procedure/supply and a related service/procedure/supply have not been met.
Start: 11/18/2005

N358

Alert: This decision may be reviewed if additional documentation as described in the contract or plan benefit documents is submitted.
Start: 11/18/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N359

Missing/incomplete/invalid height.
Start: 11/18/2005

N360

Alert: Coordination of benefits has not been calculated when estimating benefits for this pre-determination. Submit payment information from the primary payer with the secondary claim.
Start: 11/18/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N362

The number of Days or Units of Service exceeds our acceptable maximum.
Start: 11/18/2005

N363

Alert: in the near future we are implementing new policies/procedures that would affect this determination.
Start: 11/18/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N364

Alert: According to our agreement, you must waive the deductible and/or coinsurance amounts.
Start: 11/18/2005 | Last Modified: 04/01/2007
Notes: (Modified 4/1/07)

N365

This procedure code is not payable. It is for reporting/information purposes only.
Start: 04/01/2006

N366

Requested information not provided. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice.
Start: 04/01/2006

N367

Alert: The claim information has been forwarded to a Consumer Spending Account processor for review; for example, flexible spending account or health savings account.
Start: 04/01/2006 | Last Modified: 07/01/2008
Notes: (Modified 4/1/07, 11/5/07, 7/1/08)

N368

You must appeal the determination of the previously adjudicated claim.
Start: 04/01/2006

N369

Alert: Although this claim has been processed, it is deficient according to state legislation/regulation.
Start: 04/01/2006

N370

Billing exceeds the rental months covered/approved by the payer.
Start: 08/01/2006

N371

Alert: title of this equipment must be transferred to the patient.
Start: 08/01/2006

N372

Only reasonable and necessary maintenance/service charges are covered.
Start: 08/01/2006

N373

It has been determined that another payer paid the services as primary when they were not the primary payer. Therefore, we are refunding to the payer that paid as primary on your behalf.
Start: 12/01/2006

N374

Primary Medicare Part A insurance has been exhausted and a Part B Remittance Advice is required.
Start: 12/01/2006

N375

Missing/incomplete/invalid questionnaire/information required to determine dependent eligibility.
Start: 12/01/2006

N376

Subscriber/patient is assigned to active military duty, therefore primary coverage may be TRICARE.
Start: 12/01/2006

N377

Payment based on a processed replacement claim.
Start: 12/01/2006 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)

N378

Missing/incomplete/invalid prescription quantity.
Start: 12/01/2006

N379

Claim level information does not match line level information.
Start: 12/01/2006

N380

The original claim has been processed, submit a corrected claim.
Start: 04/01/2007

N381

Consult our contractual agreement for restrictions/billing/payment information related to these charges.
Start: 04/01/2007

N382

Missing/incomplete/invalid patient identifier.
Start: 04/01/2007

N383

Services deemed cosmetic are not covered
Start: 04/01/2007

N384

Records indicate that the referenced body part/tooth has been removed in a previous procedure.
Start: 04/01/2007

N385

Notification of admission was not timely according to published plan procedures.
Start: 04/01/2007 | Last Modified: 11/05/2007
Notes: (Modified 11/5/07)

N386

This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
Start: 04/01/2007

N387

Alert: Submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information.
Start: 04/01/2007 | Last Modified: 03/01/2009
Notes: (Modified 3/1/2009)

N388

Missing/incomplete/invalid prescription number
Start: 08/01/2007

N389

Duplicate prescription number submitted.
Start: 08/01/2007

N390

This service/report cannot be billed separately.
Start: 08/01/2007 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N391

Missing emergency department records.
Start: 08/01/2007

N392

Incomplete/invalid emergency department records.
Start: 08/01/2007

N393

Missing progress notes/report.
Start: 08/01/2007 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N394

Incomplete/invalid progress notes/report.
Start: 08/01/2007 | Last Modified: 07/01/2008
Notes: (Modified 7/1/08)

N395

Missing laboratory report.
Start: 08/01/2007

N396

Incomplete/invalid laboratory report.
Start: 08/01/2007

N397

Benefits are not available for incomplete service(s)/undelivered item(s).
Start: 08/01/2007

N398

Missing elective consent form.
Start: 08/01/2007

N399

Incomplete/invalid elective consent form.
Start: 08/01/2007

N400

Alert: Electronically enabled providers should submit claims electronically.
Start: 08/01/2007

N401

Missing periodontal charting.
Start: 08/01/2007

N402

Incomplete/invalid periodontal charting.
Start: 08/01/2007

N403

Missing facility certification.
Start: 08/01/2007

N404

Incomplete/invalid facility certification.
Start: 08/01/2007

N405

This service is only covered when the donor's insurer(s) do not provide coverage for the service.
Start: 08/01/2007

N406

This service is only covered when the recipient's insurer(s) do not provide coverage for the service.
Start: 08/01/2007

N407

You are not an approved submitter for this transmission format.
Start: 08/01/2007

N408

This payer does not cover deductibles assessed by a previous payer.
Start: 08/01/2007

N409

This service is related to an accidental injury and is not covered unless provided within a specific time frame from the date of the accident.
Start: 08/01/2007

N410

This is not covered unless the prescription changes.
Start: 08/01/2007

N418

Misrouted claim. See the payer's claim submission instructions.
Start: 08/01/2007

N419

Claim payment was the result of a payer's retroactive adjustment due to a retroactive rate change.
Start: 08/01/2007

N420

Claim payment was the result of a payer's retroactive adjustment due to a Coordination of Benefits or Third Party Liability Recovery.
Start: 08/01/2007

N421

Claim payment was the result of a payer's retroactive adjustment due to a review organization decision.
Start: 08/01/2007 | Last Modified: 05/08/2008
Notes: (Modified 2/29/08, typo fixed 5/8/08)

N422

Claim payment was the result of a payer's retroactive adjustment due to a payer's contract incentive program.
Start: 08/01/2007 | Last Modified: 05/08/2008
Notes: (Typo fixed 5/8/08)

N423

Claim payment was the result of a payer's retroactive adjustment due to a non standard program.
Start: 08/01/2007

N424

Patient does not reside in the geographic area required for this type of payment.
Start: 08/01/2007

N425

Statutorily excluded service(s).
Start: 08/01/2007

N426

No coverage when self-administered.
Start: 08/01/2007

N427

Payment for eyeglasses or contact lenses can be made only after cataract surgery.
Start: 08/01/2007

N428

Service/procedure not covered when performed in this place of service.
Start: 08/01/2007

N429

This is not covered since it is considered routine.
Start: 08/01/2007

N430

Procedure code is inconsistent with the units billed.
Start: 11/05/2007

N431

Service is not covered with this procedure.
Start: 11/05/2007

N432

Adjustment based on a Recovery Audit.
Start: 11/05/2007

N433

Resubmit this claim using only your National Provider Identifier (NPI)
Start: 02/29/2008

N434

Missing/Incomplete/Invalid Present on Admission indicator.
Start: 07/01/2008

N435

Exceeds number/frequency approved /allowed within time period without support documentation.
Start: 07/01/2008

N436

The injury claim has not been accepted and a mandatory medical reimbursement has been made.
Start: 07/01/2008

N437

Alert: If the injury claim is accepted, these charges will be reconsidered.
Start: 07/01/2008

N438

This jurisdiction only accepts paper claims
Start: 07/01/2008

N439

Missing anesthesia physical status report/indicators.
Start: 07/01/2008

N440

Incomplete/invalid anesthesia physical status report/indicators.
Start: 07/01/2008

N441

This missed appointment is not covered.
Start: 07/01/2008

N442

Payment based on an alternate fee schedule.
Start: 07/01/2008

N443

Missing/incomplete/invalid total time or begin/end time.
Start: 07/01/2008

N444

Alert: This facility has not filed the Election for High Cost Outlier form with the Division of Workers' Compensation.
Start: 07/01/2008

N445

Missing document for actual cost or paid amount.
Start: 07/01/2008

N446

Incomplete/invalid document for actual cost or paid amount.
Start: 07/01/2008

N447

Payment is based on a generic equivalent as required documentation was not provided.
Start: 07/01/2008

N448

This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement
Start: 07/01/2008

N449

Payment based on a comparable drug/service/supply.
Start: 07/01/2008

N450

Covered only when performed by the primary treating physician or the designee.
Start: 07/01/2008

N451

Missing Admission Summary Report.
Start: 07/01/2008

N452

Incomplete/invalid Admission Summary Report.
Start: 07/01/2008

N453

Missing Consultation Report.
Start: 07/01/2008

N454

Incomplete/invalid Consultation Report.
Start: 07/01/2008

N455

Missing Physician Order.
Start: 07/01/2008

N456

Incomplete/invalid Physician Order.
Start: 07/01/2008

N457

Missing Diagnostic Report.
Start: 07/01/2008

N458

Incomplete/invalid Diagnostic Report.
Start: 07/01/2008

N459

Missing Discharge Summary.
Start: 07/01/2008

N460

Incomplete/invalid Discharge Summary.
Start: 07/01/2008

N461

Missing Nursing Notes.
Start: 07/01/2008

N462

Incomplete/invalid Nursing Notes.
Start: 07/01/2008

N463

Missing support data for claim.
Start: 07/01/2008

N464

Incomplete/invalid support data for claim.
Start: 07/01/2008

N465

Missing Physical Therapy Notes/Report.
Start: 07/01/2008

N466

Incomplete/invalid Physical Therapy Notes/Report.
Start: 07/01/2008

N467

Missing Report of Tests and Analysis Report.
Start: 07/01/2008

N468

Incomplete/invalid Report of Tests and Analysis Report.
Start: 07/01/2008

N469

Alert: Claim/Service(s) subject to appeal process, see section 935 of Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).
Start: 07/01/2008

N470

This payment will complete the mandatory medical reimbursement limit.
Start: 07/01/2008

N471

Missing/incomplete/invalid HIPPS Rate Code.
Start: 07/01/2008

N472

Payment for this service has been issued to another provider.
Start: 07/01/2008

N473

Missing certification.
Start: 07/01/2008

N474

Incomplete/invalid certification
Start: 07/01/2008

N475

Missing completed referral form.
Start: 07/01/2008

N476

Incomplete/invalid completed referral form
Start: 07/01/2008

N477

Missing Dental Models.
Start: 07/01/2008

N478

Incomplete/invalid Dental Models
Start: 07/01/2008

N479

Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
Start: 07/01/2008

N480

Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).
Start: 07/01/2008

N481

Missing Models.
Start: 07/01/2008

N482

Incomplete/invalid Models
Start: 07/01/2008

N483

Missing Periodontal Charts.
Start: 07/01/2008

N484

Incomplete/invalid Periodontal Charts
Start: 07/01/2008

N485

Missing Physical Therapy Certification.
Start: 07/01/2008

N486

Incomplete/invalid Physical Therapy Certification.
Start: 07/01/2008

N487

Missing Prosthetics or Orthotics Certification.
Start: 07/01/2008

N488

Incomplete/invalid Prosthetics or Orthotics Certification
Start: 07/01/2008

N489

Missing referral form.
Start: 07/01/2008

N490

Incomplete/invalid referral form
Start: 07/01/2008

N491

Missing/Incomplete/Invalid Exclusionary Rider Condition.
Start: 07/01/2008

N492

Alert: A network provider may bill the member for this service if the member requested the service and agreed in writing, prior to receiving the service, to be financially responsible for the billed charge.
Start: 07/01/2008

N493

Missing Doctor First Report of Injury.
Start: 07/01/2008

N494

Incomplete/invalid Doctor First Report of Injury.
Start: 07/01/2008

N495

Missing Supplemental Medical Report.
Start: 07/01/2008

N496

Incomplete/invalid Supplemental Medical Report.
Start: 07/01/2008

N497

Missing Medical Permanent Impairment or Disability Report.
Start: 07/01/2008

N498

Incomplete/invalid Medical Permanent Impairment or Disability Report.
Start: 07/01/2008

N499

Missing Medical Legal Report.
Start: 07/01/2008

N500

Incomplete/invalid Medical Legal Report.
Start: 07/01/2008

N501

Missing Vocational Report.
Start: 07/01/2008

N502

Incomplete/invalid Vocational Report.
Start: 07/01/2008

N503

Missing Work Status Report.
Start: 07/01/2008

N504

Incomplete/invalid Work Status Report.
Start: 07/01/2008

N505

Alert: This response includes only services that could be estimated in real time. No estimate will be provided for the services that could not be estimated in real time.
Start: 11/01/2008

N506

Alert: This is an estimate of the member's liability based on the information available at the time the estimate was processed. Actual coverage and member liability amounts will be determined when the claim is processed. This is not a pre-authorization or a guarantee of payment.
Start: 11/01/2008

N507

Plan distance requirements have not been met.
Start: 11/01/2008

N508

Alert: This real time claim adjudication response represents the member responsibility to the provider for services reported. The member will receive an Explanation of Benefits electronically or in the mail. Contact the insurer if there are any questions.
Start: 11/01/2008

N509

Alert: A current inquiry shows the member's Consumer Spending Account contains sufficient funds to cover the member liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.
Start: 11/01/2008

N510

Alert: A current inquiry shows the member's Consumer Spending Account does not contain sufficient funds to cover the member's liability for this claim/service. Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing.
Start: 11/01/2008

N511

Alert: Information on the availability of Consumer Spending Account funds to cover the member liability on this claim/service is not available at this time.
Start: 11/01/2008

N512

Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time without change to the adjudication.
Start: 11/01/2008

N513

Alert: This is the initial remit of a non-NCPDP claim originally submitted real-time with a change to the adjudication.
Start: 11/01/2008

N514

Consult plan benefit documents/guidelines for information about restrictions for this service.
Start: 11/01/2008

N516

Records indicate a mismatch between the submitted NPI and EIN.
Start: 03/01/2009

N517

Resubmit a new claim with the requested information.
Start: 03/01/2009

N518

No separate payment for accessories when furnished for use with oxygen equipment.
Start: 03/01/2009

N519

Invalid combination of HCPCS modifiers.
Start: 07/01/2009

N520

Alert: Payment made from a Consumer Spending Account.
Start: 07/01/2009

APPENDIX D: Health Care Claim Status Codes - Last Update 7/1/2009 – All

Health Care Claim Status Codes convey the staus of an entire claim or a specific service line.

0 Cannot provide further status electronically.
Start: 01/01/1995

1 For more detailed information, see remittance advice.
Start: 01/01/1995

2 More detailed information in letter.
Start: 01/01/1995

3 Claim has been adjudicated and is awaiting payment cycle.
Start: 01/01/1995

4 This is a subsequent request for information from the original request.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

5 This is a final request for information.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

6 Balance due from the subscriber.
Start: 01/01/1995

7 Claim may be reconsidered at a future date.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

8 No payment due to contract/plan provisions.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

9 No payment will be made for this claim.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

10 All originally submitted procedure codes have been combined.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

11 Some originally submitted procedure codes have been combined.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

12 One or more originally submitted procedure codes have been combined.
Start: 01/01/1995 | Last Modified: 06/30/2001

13 All originally submitted procedure codes have been modified.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

14 Some all originally submitted procedure codes have been modified.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

15 One or more originally submitted procedure code have been modified.
Start: 01/01/1995 | Last Modified: 06/30/2001

16 Claim/encounter has been forwarded to entity.
Start: 01/01/1995

17 Claim/encounter has been forwarded by third party entity to entity.
Start: 01/01/1995

18 Entity received claim/encounter, but returned invalid status.
Start: 01/01/1995

19 Entity acknowledges receipt of claim/encounter.
Start: 01/01/1995 | Last Modified: 06/30/2001

20 Accepted for processing.
Start: 01/01/1995 | Last Modified: 06/30/2001

21 Missing or invalid information. Note: At least one other status code is required to identify the

missing or invalid information.
Start: 01/01/1995 | Last Modified: 07/09/2007

22 ... before entering the adjudication system.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

23 Returned to Entity.
Start: 01/01/1995 | Last Modified: 06/30/2001

24 Entity not approved as an electronic submitter.
Start: 01/01/1995 | Last Modified: 06/30/2001

25 Entity not approved.
Start: 01/01/1995 | Last Modified: 06/30/2001

26 Entity not found.
Start: 01/01/1995 | Last Modified: 06/30/2001

27 Policy canceled.
Start: 01/01/1995 | Last Modified: 06/30/2001

28 Claim submitted to wrong payer.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

29 Subscriber and policy number/contract number mismatched.
Start: 01/01/1995

30 Subscriber and subscriber id mismatched.
Start: 01/01/1995

31 Subscriber and policyholder name mismatched.
Start: 01/01/1995

32 Subscriber and policy number/contract number not found.
Start: 01/01/1995

33 Subscriber and subscriber id not found.
Start: 01/01/1995

34 Subscriber and policyholder name not found.
Start: 01/01/1995

35 Claim/encounter not found.
Start: 01/01/1995

37 Predetermination is on file, awaiting completion of services.
Start: 01/01/1995

38 Awaiting next periodic adjudication cycle.
Start: 01/01/1995

39 Charges for pregnancy deferred until delivery.
Start: 01/01/1995

40 Waiting for final approval.
Start: 01/01/1995

41 Special handling required at payer site.
Start: 01/01/1995

42 Awaiting related charges.
Start: 01/01/1995

44 Charges pending provider audit.
Start: 01/01/1995

45 Awaiting benefit determination.
Start: 01/01/1995

46 Internal review/audit.
Start: 01/01/1995

47 Internal review/audit - partial payment made.
Start: 01/01/1995

48 Referral/authorization.
Start: 01/01/1995 | Last Modified: 02/28/2001

49 Pending provider accreditation review.
Start: 01/01/1995

50 Claim waiting for internal provider verification.
Start: 01/01/1995

51 Investigating occupational illness/accident.
Start: 01/01/1995

52 Investigating existence of other insurance coverage.
Start: 01/01/1995

53 Claim being researched for Insured ID/Group Policy Number error.
Start: 01/01/1995

54 Duplicate of a previously processed claim/line.
Start: 01/01/1995

55 Claim assigned to an approver/analyst.
Start: 01/01/1995

56 Awaiting eligibility determination.
Start: 01/01/1995

57 Pending COBRA information requested.
Start: 01/01/1995

59 Non-electronic request for information.
Start: 01/01/1995

60 Electronic request for information.
Start: 01/01/1995

61 Eligibility for extended benefits.
Start: 01/01/1995

64 Re-pricing information.
Start: 01/01/1995

65 Claim/line has been paid.
Start: 01/01/1995

66 Payment reflects usual and customary charges.
Start: 01/01/1995

67 Payment made in full.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

68 Partial payment made for this claim.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

69 Payment reflects plan provisions.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

70 Payment reflects contract provisions.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

71 Periodic installment released.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

72 Claim contains split payment.
Start: 01/01/1995

73 Payment made to entity, assignment of benefits not on file.
Start: 01/01/1995

78 Duplicate of an existing claim/line, awaiting processing.
Start: 01/01/1995

81 Contract/plan does not cover pre-existing conditions.
Start: 01/01/1995

83 No coverage for newborns.
Start: 01/01/1995

84 Service not authorized.
Start: 01/01/1995

85 Entity not primary.
Start: 01/01/1995

86 Diagnosis and patient gender mismatch.
Start: 01/01/1995 | Last Modified: 02/28/2000

87 Denied: Entity not found. (Use code 26 with appropriate Claim Status category Code)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

88 Entity not eligible for benefits for submitted dates of service.
Start: 01/01/1995

89 Entity not eligible for dental benefits for submitted dates of service.
Start: 01/01/1995

90 Entity not eligible for medical benefits for submitted dates of service.
Start: 01/01/1995

91 Entity not eligible/not approved for dates of service.
Start: 01/01/1995

92 Entity does not meet dependent or student qualification.
Start: 01/01/1995

93 Entity is not selected primary care provider.
Start: 01/01/1995

94 Entity not referred by selected primary care provider.
Start: 01/01/1995

95 Requested additional information not received.
Start: 01/01/1995 | Last Modified: 07/09/2007
Notes: If known, the payer must report a second claim status code identifying the requested information.

96 No agreement with entity.
Start: 01/01/1995

97 Patient eligibility not found with entity.
Start: 01/01/1995

98 Charges applied to deductible.
Start: 01/01/1995

99 Pre-treatment review.
Start: 01/01/1995

100 Pre-certification penalty taken.
Start: 01/01/1995

101 Claim was processed as adjustment to previous claim.
Start: 01/01/1995

102 Newborn's charges processed on mother's claim.
Start: 01/01/1995

103 Claim combined with other claim(s).
Start: 01/01/1995

104 Processed according to plan provisions (Plan refers to provisions that exist between the

Health Plan and the Consumer or Patient)
Start: 01/01/1995 | Last Modified: 06/01/2008

105 Claim/line is capitated.
Start: 01/01/1995

106 This amount is not entity's responsibility.
Start: 01/01/1995

107 Processed according to contract provisions (Contract refers to provisions that exist between

the Health Plan and a Provider of Health Care Services)
Start: 01/01/1995 | Last Modified: 06/01/2008

108 Coverage has been canceled for this entity. (Use code 27)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

109 Entity not eligible.
Start: 01/01/1995

110 Claim requires pricing information.
Start: 01/01/1995

111 At the policyholder's request these claims cannot be submitted electronically.
Start: 01/01/1995

112 Policyholder processes their own claims.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

113 Cannot process individual insurance policy claims.
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

114 Claim/service should be processed by entity.
Start: 01/01/1995 | Last Modified: 01/27/2008

115 Cannot process HMO claims
Start: 01/01/1995 | Last Modified: 01/27/2008 | Stop: 07/01/2008

116 Claim submitted to incorrect payer.
Start: 01/01/1995

117 Claim requires signature-on-file indicator.
Start: 01/01/1995

118 TPO rejected claim/line because payer name is missing. (Use status code 21 and status

code 125 with entity code IN)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

119 TPO rejected claim/line because certification information is missing. (Use status code 21

and status code 252)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

120 TPO rejected claim/line because claim does not contain enough information. (Use status code 21)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

121 Service line number greater than maximum allowable for payer.
Start: 01/01/1995

122 Missing/invalid data prevents payer from processing claim. (Use CSC Code 21)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

123 Additional information requested from entity.
Start: 01/01/1995

124 Entity's name, address, phone and id number.
Start: 01/01/1995

125 Entity's name.
Start: 01/01/1995

126 Entity's address.
Start: 01/01/1995

127 Entity's phone number.
Start: 01/01/1995

128 Entity's tax id.
Start: 01/01/1995

129 Entity's Blue Cross provider id
Start: 01/01/1995

130 Entity's Blue Shield provider id
Start: 01/01/1995

131 Entity's Medicare provider id.
Start: 01/01/1995

132 Entity's Medicaid provider id.
Start: 01/01/1995

133 Entity's UPIN
Start: 01/01/1995

134 Entity's CHAMPUS provider id.
Start: 01/01/1995

135 Entity's commercial provider id.
Start: 01/01/1995

136 Entity's health industry id number.
Start: 01/01/1995

137 Entity's plan network id.
Start: 01/01/1995

138 Entity's site id .
Start: 01/01/1995

139 Entity's health maintenance provider id (HMO).
Start: 01/01/1995

140 Entity's preferred provider organization id (PPO).
Start: 01/01/1995 | Last Modified: 06/30/2001

141 Entity's administrative services organization id (ASO).
Start: 01/01/1995

142 Entity's license/certification number.
Start: 01/01/1995

143 Entity's state license number.
Start: 01/01/1995

144 Entity's specialty license number.
Start: 01/01/1995

145 Entity's specialty/taxonomy code.
Start: 01/01/1995 | Last Modified: 09/30/2007

146 Entity's anesthesia license number.
Start: 01/01/1995

147 Entity's qualification degree/designation (e.g. RN,PhD,MD)
Start: 02/28/1997

148 Entity's social security number.
Start: 01/01/1995

149 Entity's employer id.
Start: 01/01/1995

150 Entity's drug enforcement agency (DEA) number.
Start: 01/01/1995

152 Pharmacy processor number.
Start: 01/01/1995

153 Entity's id number.
Start: 01/01/1995

154 Relationship of surgeon & assistant surgeon.
Start: 01/01/1995

155 Entity's relationship to patient
Start: 01/01/1995

156 Patient relationship to subscriber
Start: 01/01/1995

157 Entity's Gender
Start: 01/01/1995

158 Entity's date of birth
Start: 01/01/1995

159 Entity's date of death
Start: 01/01/1995

160 Entity's marital status
Start: 01/01/1995

161 Entity's employment status
Start: 01/01/1995

162 Entity's health insurance claim number (HICN).
Start: 01/01/1995

163 Entity's policy number.
Start: 01/01/1995

164 Entity's contract/member number.
Start: 01/01/1995

165 Entity's employer name, address and phone.
Start: 01/01/1995

166 Entity's employer name.
Start: 01/01/1995

167 Entity's employer address.
Start: 01/01/1995

168 Entity's employer phone number.
Start: 01/01/1995

169 Entity's employer id.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

170 Entity's employee id.
Start: 01/01/1995

171 Other insurance coverage information (health, liability, auto, etc.).
Start: 01/01/1995

172 Other employer name, address and telephone number.
Start: 01/01/1995

173 Entity's name, address, phone, gender, DOB, marital status, employment status and relation to subscriber.
Start: 01/01/1995 | Last Modified: 02/28/2000

174 Entity's student status.
Start: 01/01/1995

175 Entity's school name.
Start: 01/01/1995

176 Entity's school address.
Start: 01/01/1995

177 Transplant recipient's name, date of birth, gender, relationship to insured.
Start: 01/01/1995 | Last Modified: 02/28/2000

178 Submitted charges.
Start: 01/01/1995

179 Outside lab charges.
Start: 01/01/1995

180 Hospital s semi-private room rate.
Start: 01/01/1995

181 Hospital s room rate.
Start: 01/01/1995

182 Allowable/paid from primary coverage.
Start: 01/01/1995

183 Amount entity has paid.
Start: 01/01/1995

184 Purchase price for the rented durable medical equipment.
Start: 01/01/1995

185 Rental price for durable medical equipment.
Start: 01/01/1995

186 Purchase and rental price of durable medical equipment.
Start: 01/01/1995

187 Date(s) of service.
Start: 01/01/1995

188 Statement from-through dates.
Start: 01/01/1995

189 Facility admission date
Start: 01/01/1995 | Last Modified: 10/31/2006

190 Facility discharge date
Start: 01/01/1995 | Last Modified: 10/31/2006

191 Date of Last Menstrual Period (LMP)
Start: 02/28/1997

192 Date of first service for current series/symptom/illness.
Start: 01/01/1995

193 First consultation/evaluation date.
Start: 02/28/1997

194 Confinement dates.
Start: 01/01/1995

195 Unable to work dates.
Start: 01/01/1995

196 Return to work dates.
Start: 01/01/1995

197 Effective coverage date(s).
Start: 01/01/1995

198 Medicare effective date.
Start: 01/01/1995

199 Date of conception and expected date of delivery.
Start: 01/01/1995

200 Date of equipment return.
Start: 01/01/1995

201 Date of dental appliance prior placement.
Start: 01/01/1995

202 Date of dental prior replacement/reason for replacement.
Start: 01/01/1995

203 Date of dental appliance placed.
Start: 01/01/1995

204 Date dental canal(s) opened and date service completed.
Start: 01/01/1995

205 Date(s) dental root canal therapy previously performed.
Start: 01/01/1995

206 Most recent date of curettage, root planing, or periodontal surgery.
Start: 01/01/1995

207 Dental impression and seating date.
Start: 01/01/1995

208 Most recent date pacemaker was implanted.
Start: 01/01/1995

209 Most recent pacemaker battery change date.
Start: 01/01/1995

210 Date of the last x-ray.
Start: 01/01/1995

211 Date(s) of dialysis training provided to patient.
Start: 01/01/1995

212 Date of last routine dialysis.
Start: 01/01/1995

213 Date of first routine dialysis.
Start: 01/01/1995

214 Original date of prescription/orders/referral.
Start: 02/28/1997

215 Date of tooth extraction/evolution.
Start: 01/01/1995

216 Drug information.
Start: 01/01/1995

217 Drug name, strength and dosage form.
Start: 01/01/1995

218 NDC number.
Start: 01/01/1995

219 Prescription number.
Start: 01/01/1995

220 Drug product id number.
Start: 01/01/1995

221 Drug days supply and dosage.
Start: 01/01/1995

222 Drug dispensing units and average wholesale price (AWP).
Start: 01/01/1995

223 Route of drug/myelogram administration.
Start: 01/01/1995

224 Anatomical location for joint injection.
Start: 01/01/1995

225 Anatomical location.
Start: 01/01/1995

226 Joint injection site.
Start: 01/01/1995

227 Hospital information.
Start: 01/01/1995

228 Type of bill for UB claim
Start: 01/01/1995 | Last Modified: 10/31/2006

229 Hospital admission source.
Start: 01/01/1995

230 Hospital admission hour.
Start: 01/01/1995

231 Hospital admission type.
Start: 01/01/1995

232 Admitting diagnosis.
Start: 01/01/1995

233 Hospital discharge hour.
Start: 01/01/1995

234 Patient discharge status.
Start: 01/01/1995

235 Units of blood furnished.
Start: 01/01/1995

236 Units of blood replaced.
Start: 01/01/1995

237 Units of deductible blood.
Start: 01/01/1995

238 Separate claim for mother/baby charges.
Start: 01/01/1995

239 Dental information.
Start: 01/01/1995

240 Tooth surface(s) involved.
Start: 01/01/1995

241 List of all missing teeth (upper and lower).
Start: 01/01/1995

242 Tooth numbers, surfaces, and/or quadrants involved.
Start: 01/01/1995

243 Months of dental treatment remaining.
Start: 01/01/1995

244 Tooth number or letter.
Start: 01/01/1995

245 Dental quadrant/arch.
Start: 01/01/1995

246 Total orthodontic service fee, initial appliance fee, monthly fee, length of service.
Start: 01/01/1995

247 Line information.
Start: 01/01/1995

248 Accident date, state, description and cause.
Start: 01/01/1995

249 Place of service.
Start: 01/01/1995

250 Type of service.
Start: 01/01/1995

251 Total anesthesia minutes.
Start: 01/01/1995

252 Authorization/certification number.
Start: 01/01/1995

253 Procedure/revenue code for service(s) rendered. Use codes 454 or 455.
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997

254 Primary diagnosis code.
Start: 01/01/1995

255 Diagnosis code.
Start: 01/01/1995

256 DRG code(s).
Start: 01/01/1995

257 ADSM-III-R code for services rendered.
Start: 01/01/1995

258 Days/units for procedure/revenue code.
Start: 01/01/1995

259 Frequency of service.
Start: 01/01/1995

260 Length of medical necessity, including begin date.
Start: 02/28/1997

261 Obesity measurements.
Start: 01/01/1995

262 Type of surgery/service for which anesthesia was administered.
Start: 01/01/1995

263 Length of time for services rendered.
Start: 01/01/1995

264 Number of liters/minute & total hours/day for respiratory support.
Start: 01/01/1995

265 Number of lesions excised.
Start: 01/01/1995

266 Facility point of origin and destination - ambulance.
Start: 01/01/1995

267 Number of miles patient was transported.
Start: 01/01/1995

268 Location of durable medical equipment use.
Start: 01/01/1995

269 Length/size of laceration/tumor.
Start: 01/01/1995

270 Subluxation location.
Start: 01/01/1995

271 Number of spine segments.
Start: 01/01/1995

272 Oxygen contents for oxygen system rental.
Start: 01/01/1995

273 Weight.
Start: 01/01/1995

274 Height.
Start: 01/01/1995

275 Claim.
Start: 01/01/1995

276 UB04/HCFA-1450/1500 claim form
Start: 01/01/1995 | Last Modified: 10/31/2006

277 Paper claim.
Start: 01/01/1995

278 Signed claim form.
Start: 01/01/1995

279 Itemized claim.
Start: 01/01/1995

280 Itemized claim by provider.
Start: 01/01/1995

281 Related confinement claim.
Start: 01/01/1995

282 Copy of prescription.
Start: 01/01/1995

283 Medicare entitlement information is required to determine primary coverage
Start: 01/01/1995 | Last Modified: 01/27/2008

284 Copy of Medicare ID card.
Start: 01/01/1995

285 Vouchers/explanation of benefits (EOB).
Start: 01/01/1995

286 Other payer's Explanation of Benefits/payment information.
Start: 01/01/1995

287 Medical necessity for service.
Start: 01/01/1995

288 Reason for late hospital charges.
Start: 01/01/1995

289 Reason for late discharge.
Start: 01/01/1995

290 Pre-existing information.
Start: 01/01/1995

291 Reason for termination of pregnancy.
Start: 01/01/1995

292 Purpose of family conference/therapy.
Start: 01/01/1995

293 Reason for physical therapy.
Start: 01/01/1995

294 Supporting documentation.
Start: 01/01/1995

295 Attending physician report.
Start: 01/01/1995

296 Nurse's notes.
Start: 01/01/1995

297 Medical notes/report.
Start: 02/28/1997

298 Operative report.
Start: 01/01/1995

299 Emergency room notes/report.
Start: 01/01/1995

300 Lab/test report/notes/results.
Start: 02/28/1997

301 MRI report.
Start: 01/01/1995

302 Refer to codes 300 for lab notes and 311 for pathology notes
Start: 01/01/1995 | Stop: 01/31/1997

303 Physical therapy notes. Use code 297:6O (6 'OH' - not zero)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997

304 Reports for service.
Start: 01/01/1995

305 X-ray reports/interpretation.
Start: 01/01/1995

306 Detailed description of service.
Start: 01/01/1995

307 Narrative with pocket depth chart.
Start: 01/01/1995

308 Discharge summary.
Start: 01/01/1995

309 Code was duplicate of code 299
Start: 01/01/1995 | Stop: 01/31/1997

310 Progress notes for the six months prior to statement date.
Start: 01/01/1995

311 Pathology notes/report.
Start: 01/01/1995

312 Dental charting.
Start: 01/01/1995

313 Bridgework information.
Start: 01/01/1995

314 Dental records for this service.
Start: 01/01/1995

315 Past perio treatment history.
Start: 01/01/1995

316 Complete medical history.
Start: 01/01/1995

317 Patient's medical records.
Start: 01/01/1995

318 X-rays.
Start: 01/01/1995

319 Pre/post-operative x-rays/photographs.
Start: 02/28/1997

320 Study models.
Start: 01/01/1995

321 Radiographs or models.
Start: 01/01/1995

322 Recent fm x-rays.
Start: 01/01/1995

323 Study models, x-rays, and/or narrative.
Start: 01/01/1995

324 Recent x-ray of treatment area and/or narrative.
Start: 01/01/1995

325 Recent fm x-rays and/or narrative.
Start: 01/01/1995

326 Copy of transplant acquisition invoice.
Start: 01/01/1995

327 Periodontal case type diagnosis and recent pocket depth chart with narrative.
Start: 01/01/1995

328 Speech therapy notes. Use code 297:6R
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997

329 Exercise notes.
Start: 01/01/1995

330 Occupational notes.
Start: 01/01/1995

331 History and physical.
Start: 01/01/1995 | Last Modified: 08/01/2007

332 Authorization/certification (include period covered). (Use code 252)
Start: 02/28/1997 | Last Modified: 07/09/2007 | Stop: 01/01/2008

333 Patient release of information authorization.
Start: 01/01/1995

334 Oxygen certification.
Start: 01/01/1995

335 Durable medical equipment certification.
Start: 01/01/1995

336 Chiropractic certification.
Start: 01/01/1995

337 Ambulance certification/documentation.
Start: 01/01/1995

338 Home health certification. Use code 332:4Y
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997

339 Enteral/parenteral certification.
Start: 01/01/1995

340 Pacemaker certification.
Start: 01/01/1995

341 Private duty nursing certification.
Start: 01/01/1995

342 Podiatric certification.
Start: 01/01/1995

343 Documentation that facility is state licensed and Medicare approved as a surgical facility.
Start: 01/01/1995

344 Documentation that provider of physical therapy is Medicare Part B approved.
Start: 01/01/1995

345 Treatment plan for service/diagnosis
Start: 01/01/1995

346 Proposed treatment plan for next 6 months.
Start: 01/01/1995

347 Refer to code 345 for treatment plan and code 282 for prescription
Start: 01/01/1995 | Stop: 01/31/1997

348 Chiropractic treatment plan. (Use 345:QL)
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 01/01/2008

349 Psychiatric treatment plan. Use codes 345:5I, 5J, 5K, 5L, 5M, 5N, 5O (5 'OH' - not zero), 5P
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997

350 Speech pathology treatment plan. Use code 345:6R
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997

351 Physical/occupational therapy treatment plan. Use codes 345:6O (6 'OH' - not zero), 6N
Start: 01/01/1995 | Last Modified: 07/09/2007 | Stop: 02/28/1997

352 Duration of treatment plan.
Start: 01/01/1995

353 Orthodontics treatment plan.
Start: 01/01/1995

354 Treatment plan for replacement of remaining missing teeth.
Start: 01/01/1995

355 Has claim been paid?
Start: 01/01/1995

356 Was blood furnished?
Start: 01/01/1995

357 Has or will blood be replaced?
Start: 01/01/1995

358 Does provider accept assignment of benefits?
Start: 01/01/1995

359 Is there a release of information signature on file?
Start: 01/01/1995

360 Is there an assignment of benefits signature on file?
Start: 01/01/1995

361 Is there other insurance?
Start: 01/01/1995

362 Is the dental patient covered by medical insurance?
Start: 01/01/1995

363 Will worker's compensation cover submitted charges?
Start: 01/01/1995

364 Is accident/illness/condition employment related?
Start: 01/01/1995

365 Is service the result of an accident?
Start: 01/01/1995

366 Is injury due to auto accident?
Start: 01/01/1995

367 Is service performed for a recurring condition or new condition?
Start: 01/01/1995

368 Is medical doctor (MD) or doctor of osteopath (DO) on staff of this facility?
Start: 01/01/1995

369 Does patient condition preclude use of ordinary bed?
Start: 01/01/1995

370 Can patient operate controls of bed?
Start: 01/01/1995

371 Is patient confined to room?
Start: 01/01/1995

372 Is patient confined to bed?
Start: 01/01/1995

373 Is patient an insulin diabetic?
Start: 01/01/1995

374 Is prescribed lenses a result of cataract surgery?
Start: 01/01/1995

375 Was refraction performed?
Start: 01/01/1995

376 Was charge for ambulance for a round-trip?
Start: 01/01/1995

377 Was durable medical equipment purchased new or used?
Start: 01/01/1995

378 Is pacemaker temporary or permanent?
Start: 01/01/1995

379 Were services performed supervised by a physician?
Start: 01/01/1995

380 Were services performed by a CRNA under appropriate medical direction?
Start: 01/01/1995 | Last Modified: 10/31/1999

381 Is drug generic?
Start: 01/01/1995

382 Did provider authorize generic or brand name dispensing?
Start: 01/01/1995

383 Was nerve block used for surgical procedure or pain management?
Start: 01/01/1995

384 Is prosthesis/crown/inlay placement an initial placement or a replacement?
Start: 01/01/1995

385 Is appliance upper or lower arch & is appliance fixed or removable?
Start: 01/01/1995

386 Is service for orthodontic purposes?
Start: 01/01/1995

387 Date patient last examined by entity
Start: 02/28/1997

388 Date post-operative care assumed
Start: 02/28/1997

389 Date post-operative care relinquished
Start: 02/28/1997

390 Date of most recent medical event necessitating service(s)
Start: 02/28/1997

391 Date(s) dialysis conducted
Start: 02/28/1997

392 Date(s) of blood transfusion(s)
Start: 02/28/1997

393 Date of previous pacemaker check
Start: 02/28/1997

394 Date(s) of most recent hospitalization related to service
Start: 02/28/1997

395 Date entity signed certification/recertification
Start: 02/28/1997

396 Date home dialysis began
Start: 02/28/1997

397 Date of onset/exacerbation of illness/condition
Start: 02/28/1997

398 Visual field test results
Start: 02/28/1997

399 Report of prior testing related to this service, including dates
Start: 02/28/1997

400 Claim is out of balance
Start: 02/28/1997

401 Source of payment is not valid
Start: 02/28/1997

402 Amount must be greater than zero. This change to be effective 10/1/2009: Amount must

be greater than zero. Note: At least one other status code is required to identify which

amount element is in error.
Start: 02/28/1997 | Last Modified: 01/25/2009

403 Entity referral notes/orders/prescription
Start: 02/28/1997

404 Specific findings, complaints, or symptoms necessitating service
Start: 02/28/1997

405 Summary of services
Start: 02/28/1997

406 Brief medical history as related to service(s)
Start: 02/28/1997

407 Complications/mitigating circumstances
Start: 02/28/1997

408 Initial certification
Start: 02/28/1997

409 Medication logs/records (including medication therapy)
Start: 02/28/1997

410 Explain differences between treatment plan and patient's condition
Start: 02/28/1997

411 Medical necessity for non-routine service(s)
Start: 02/28/1997

412 Medical records to substantiate decision of non-coverage
Start: 02/28/1997

413 Explain/justify differences between treatment plan and services rendered.
Start: 02/28/1997

414 Need for more than one physician to treat patient
Start: 02/28/1997

415 Justify services outside composite rate
Start: 02/28/1997

416 Verification of patient's ability to retain and use information
Start: 02/28/1997

417 Prior testing, including result(s) and date(s) as related to service(s)
Start: 02/28/1997

418 Indicating why medications cannot be taken orally
Start: 02/28/1997

419 Individual test(s) comprising the panel and the charges for each test
Start: 02/28/1997

420 Name, dosage and medical justification of contrast material used for radiology procedure
Start: 02/28/1997

421 Medical review attachment/information for service(s)
Start: 02/28/1997

422 Homebound status
Start: 02/28/1997

423 Prognosis
Start: 02/28/1997 | Last Modified: 07/09/2007 | Stop: 01/01/2008

424 Statement of non-coverage including itemized bill
Start: 02/28/1997

425 Itemize non-covered services
Start: 02/28/1997

426 All current diagnoses
Start: 02/28/1997

427 Emergency care provided during transport
Start: 02/28/1997

428 Reason for transport by ambulance
Start: 02/28/1997

429 Loaded miles and charges for transport to nearest facility with appropriate services
Start: 02/28/1997

430 Nearest appropriate facility
Start: 02/28/1997

431 Provide condition/functional status at time of service
Start: 02/28/1997

432 Date benefits exhausted
Start: 02/28/1997

433 Copy of patient revocation of hospice benefits
Start: 02/28/1997

434 Reasons for more than one transfer per entitlement period
Start: 02/28/1997

435 Notice of Admission
Start: 02/28/1997

436 Short term goals
Start: 02/28/1997

437 Long term goals
Start: 02/28/1997

438 Number of patients attending session
Start: 02/28/1997

439 Size, depth, amount, and type of drainage wounds
Start: 02/28/1997

440 why non-skilled caregiver has not been taught procedure
Start: 02/28/1997

441 Entity professional qualification for service(s)
Start: 02/28/1997

442 Modalities of service
Start: 02/28/1997

443 Initial evaluation report
Start: 02/28/1997

444 Method used to obtain test sample
Start: 02/28/1997

445 Explain why hearing loss not correctable by hearing aid
Start: 02/28/1997

446 Documentation from prior claim(s) related to service(s)
Start: 02/28/1997

447 Plan of teaching
Start: 02/28/1997

448 Invalid billing combination. See STC12 for details. This code should only be used to

indicate an inconsistency between two or more data elements on the claim. A detailed

explanation is required in STC12 when this code is used.
Start: 02/28/1997

449 Projected date to discontinue service(s)
Start: 02/28/1997

450 Awaiting spend down determination
Start: 02/28/1997

451 Preoperative and post-operative diagnosis
Start: 02/28/1997

452 Total visits in total number of hours/day and total number of hours/week
Start: 02/28/1997

453 Procedure Code Modifier(s) for Service(s) Rendered
Start: 02/28/1997

454 Procedure code for services rendered.
Start: 02/28/1997

455 Revenue code for services rendered.
Start: 02/28/1997

456 Covered Day(s)
Start: 02/28/1997

457 Non-Covered Day(s)
Start: 02/28/1997

458 Coinsurance Day(s)
Start: 02/28/1997

459 Lifetime Reserve Day(s)
Start: 02/28/1997

460 NUBC Condition Code(s)
Start: 02/28/1997

461 NUBC Occurrence Code(s) and Date(s)
Start: 02/28/1997

462 NUBC Occurrence Span Code(s) and Date(s)
Start: 02/28/1997

463 NUBC Value Code(s) and/or Amount(s)
Start: 02/28/1997

464 Payer Assigned Claim Control Number
Start: 02/28/1997 | Last Modified: 10/31/2004

465 Principal Procedure Code for Service(s) Rendered
Start: 02/28/1997

466 Entities Original Signature
Start: 02/28/1997

467 Entity Signature Date
Start: 02/28/1997

468 Patient Signature Source
Start: 02/28/1997

469 Purchase Service Charge
Start: 02/28/1997

470 Was service purchased from another entity?
Start: 02/28/1997

471 Were services related to an emergency?
Start: 02/28/1997

472 Ambulance Run Sheet
Start: 02/28/1997

473 Missing or invalid lab indicator
Start: 06/30/1998

474 Procedure code and patient gender mismatch
Start: 06/30/1998 | Last Modified: 02/29/2000

475 Procedure code not valid for patient age
Start: 06/30/1998 | Last Modified: 02/29/2000

476 Missing or invalid units of service
Start: 06/30/1998

477 Diagnosis code pointer is missing or invalid
Start: 06/30/1998

478 Claim submitter's identifier (patient account number) is missing
Start: 06/30/1998

479 Other Carrier payer ID is missing or invalid
Start: 06/30/1998

480 Other Carrier Claim filing indicator is missing or invalid
Start: 06/30/1998

481 Claim/submission format is invalid.
Start: 10/31/1998

482 Date Error, Century Missing
Start: 02/28/1999

483 Maximum coverage amount met or exceeded for benefit period.
Start: 06/30/1999

484 Business Application Currently Not Available
Start: 02/29/2000

485 More information available than can be returned in real time mode. Narrow your current search criteria.
Start: 02/28/2001

486 Principal Procedure Date
Start: 10/31/2001 | Last Modified: 07/01/2009

487 Claim not found, claim should have been submitted to/through 'entity'
Start: 02/28/2002

488 Diagnosis code(s) for the services rendered.
Start: 06/30/2002

489 Attachment Control Number
Start: 10/31/2002

490 Other Procedure Code for Service(s) Rendered
Start: 02/28/2003

491 Entity not eligible for encounter submission
Start: 02/28/2003

492 Other Procedure Date
Start: 02/28/2003

493 Version/Release/Industry ID code not currently supported by information holder
Start: 02/28/2003

494 Real-Time requests not supported by the information holder, resubmit as batch request
Start: 02/28/2003

495 Requests for re-adjudication must reference the newly assigned payer claim control number

for this previously adjusted claim. Correct the payer claim control number and re-submit.
Start: 10/31/2003

496 Submitter not approved for electronic claim submissions on behalf of this entity
Start: 02/29/2004

497 Sales tax not paid
Start: 06/30/2004

498 Maximum leave days exhausted
Start: 06/30/2004

499 No rate on file with the payer for this service for this entity
Start: 06/30/2004

500 Entity's Postal/Zip Code
Start: 06/30/2004

501 Entity's State/Province
Start: 06/30/2004

502 Entity's City
Start: 06/30/2004

503 Entity's Street Address
Start: 06/30/2004

504 Entity's Last Name
Start: 06/30/2004

505 Entity's First Name
Start: 06/30/2004

506 Entity is changing processor/clearinghouse. This claim must be submitted to the new

processor/clearinghouse
Start: 06/30/2004

507 HCPCS
Start: 10/31/2004

508 ICD9 This change to be effective 04/01/2010: ICD9 NOTE: At least one other status code is

required to identify the related procedure code or diagnosis code.
Start: 10/31/2004 | Last Modified: 07/01/2009

509 E-Code
Start: 10/31/2004

510 Future date
Start: 10/31/2004

511 Invalid character
Start: 10/31/2004

512 Length invalid for receiver's application system
Start: 10/31/2004

513 HIPPS Rate Code for services Rendered
Start: 10/31/2004

514 Entities Middle Name
Start: 10/31/2004

515 Managed Care review
Start: 10/31/2004

516 Adjudication or Payment Date
Start: 10/31/2004

517 Adjusted Repriced Claim Reference Number
Start: 10/31/2004

518 Adjusted Repriced Line item Reference Number
Start: 10/31/2004

519 Adjustment Amount
Start: 10/31/2004

520 Adjustment Quantity
Start: 10/31/2004

521 Adjustment Reason Code
Start: 10/31/2004

522 Anesthesia Modifying Units
Start: 10/31/2004

523 Anesthesia Unit Count
Start: 10/31/2004

524 Arterial Blood Gas Quantity
Start: 10/31/2004

525 Begin Therapy Date
Start: 10/31/2004

526 Bundled or Unbundled Line Number
Start: 10/31/2004

527 Certification Condition Indicator
Start: 10/31/2004

528 Certification Period Projected Visit Count
Start: 10/31/2004

529 Certification Revision Date
Start: 10/31/2004

530 Claim Adjustment Indicator
Start: 10/31/2004

531 Claim Disproportinate Share Amount
Start: 10/31/2004

532 Claim DRG Amount
Start: 10/31/2004

533 Claim DRG Outlier Amount
Start: 10/31/2004

534 Claim ESRD Payment Amount
Start: 10/31/2004

535 Claim Frequency Code
Start: 10/31/2004

536 Claim Indirect Teaching Amount
Start: 10/31/2004

537 Claim MSP Pass-through Amount
Start: 10/31/2004

538 Claim or Encounter Identifier
Start: 10/31/2004

539 Claim PPS Capital Amount
Start: 10/31/2004

540 Claim PPS Capital Outlier Amount
Start: 10/31/2004

541 Claim Submission Reason Code
Start: 10/31/2004

542 Claim Total Denied Charge Amount
Start: 10/31/2004

543 Clearinghouse or Value Added Network Trace
Start: 10/31/2004

544 Clinical Laboratory Improvement Amendment
Start: 10/31/2004

545 Contract Amount
Start: 10/31/2004

546 Contract Code
Start: 10/31/2004

547 Contract Percentage
Start: 10/31/2004

548 Contract Type Code
Start: 10/31/2004

549 Contract Version Identifier
Start: 10/31/2004

550 Coordination of Benefits Code
Start: 10/31/2004

551 Coordination of Benefits Total Submitted Charge
Start: 10/31/2004

552 Cost Report Day Count
Start: 10/31/2004

553 Covered Amount
Start: 10/31/2004

554 Date Claim Paid
Start: 10/31/2004

555 Delay Reason Code
Start: 10/31/2004

556 Demonstration Project Identifier
Start: 10/31/2004

557 Diagnosis Date
Start: 10/31/2004

558 Discount Amount
Start: 10/31/2004

559 Document Control Identifier
Start: 10/31/2004

560 Entity's Additional/Secondary Identifier
Start: 10/31/2004

561 Entity's Contact Name
Start: 10/31/2004

562 Entity's National Provider Identifier (NPI)
Start: 10/31/2004

563 Entity's Tax Amount
Start: 10/31/2004

564 EPSDT Indicator
Start: 10/31/2004

565 Estimated Claim Due Amount
Start: 10/31/2004

566 Exception Code
Start: 10/31/2004

567 Facility Code Qualifier
Start: 10/31/2004

568 Family Planning Indicator
Start: 10/31/2004

569 Fixed Format Information
Start: 10/31/2004

570 Free Form Message Text
Start: 10/31/2004

571 Frequency Count
Start: 10/31/2004

572 Frequency Period
Start: 10/31/2004

573 Functional Limitation Code
Start: 10/31/2004

574 HCPCS Payable Amount Home Health
Start: 10/31/2004

575 Homebound Indicator
Start: 10/31/2004

576 Immunization Batch Number
Start: 10/31/2004

577 Industry Code
Start: 10/31/2004

578 Insurance Type Code
Start: 10/31/2004

579 Investigational Device Exemption Identifier
Start: 10/31/2004

580 Last Certification Date
Start: 10/31/2004

581 Last Worked Date
Start: 10/31/2004

582 Lifetime Psychiatric Days Count
Start: 10/31/2004

583 Line Item Charge Amount
Start: 10/31/2004

584 Line Item Control Number
Start: 10/31/2004

585 Denied Charge or Non-covered Charge
Start: 10/31/2004 | Last Modified: 07/09/2007

586 Line Note Text
Start: 10/31/2004

587 Measurement Reference Identification Code
Start: 10/31/2004

588 Medical Record Number
Start: 10/31/2004

589 Medicare Assignment Code
Start: 10/31/2004

590 Medicare Coverage Indicator
Start: 10/31/2004

591 Medicare Paid at 100% Amount
Start: 10/31/2004

592 Medicare Paid at 80% Amount
Start: 10/31/2004

593 Medicare Section 4081 Indicator
Start: 10/31/2004

594 Mental Status Code
Start: 10/31/2004

595 Monthly Treatment Count
Start: 10/31/2004

596 Non-covered Charge Amount
Start: 10/31/2004

597 Non-payable Professional Component Amount
Start: 10/31/2004

598 Non-payable Professional Component Billed Amount
Start: 10/31/2004

599 Note Reference Code
Start: 10/31/2004

600 Oxygen Saturation Qty
Start: 10/31/2004

601 Oxygen Test Condition Code
Start: 10/31/2004

602 Oxygen Test Date
Start: 10/31/2004

603 Old Capital Amount
Start: 10/31/2004

604 Originator Application Transaction Identifier
Start: 10/31/2004

605 Orthodontic Treatment Months Count
Start: 10/31/2004

606 Paid From Part A Medicare Trust Fund Amount
Start: 10/31/2004

607 Paid From Part B Medicare Trust Fund Amount
Start: 10/31/2004

608 Paid Service Unit Count
Start: 10/31/2004

609 Participation Agreement
Start: 10/31/2004

610 Patient Discharge Facility Type Code
Start: 10/31/2004

611 Peer Review Authorization Number
Start: 10/31/2004

612 Per Day Limit Amount
Start: 10/31/2004

613 Physician Contact Date
Start: 10/31/2004

614 Physician Order Date
Start: 10/31/2004

615 Policy Compliance Code
Start: 10/31/2004

616 Policy Name
Start: 10/31/2004

617 Postage Claimed Amount
Start: 10/31/2004

618 PPS-Capital DSH DRG Amount
Start: 10/31/2004

619 PPS-Capital Exception Amount
Start: 10/31/2004

620 PPS-Capital FSP DRG Amount
Start: 10/31/2004

621 PPS-Capital HSP DRG Amount
Start: 10/31/2004

622 PPS-Capital IME Amount
Start: 10/31/2004

623 PPS-Operating Federal Specific DRG Amount
Start: 10/31/2004

624 PPS-Operating Hospital Specific DRG Amount
Start: 10/31/2004

625 Predetermination of Benefits Identifier
Start: 10/31/2004

626 Pregnancy Indicator
Start: 10/31/2004

627 Pre-Tax Claim Amount
Start: 10/31/2004

628 Pricing Methodology
Start: 10/31/2004

629 Property Casualty Claim Number
Start: 10/31/2004

630 Referring CLIA Number
Start: 10/31/2004

631 Reimbursement Rate
Start: 10/31/2004

632 Reject Reason Code
Start: 10/31/2004

633 Related Causes Code
Start: 10/31/2004

634 Remark Code
Start: 10/31/2004

635 Repriced Approved Ambulatory Patient Group
Start: 10/31/2004

636 Repriced Line Item Reference Number
Start: 10/31/2004

637 Repriced Saving Amount
Start: 10/31/2004

638 Repricing Per Diem or Flat Rate Amount
Start: 10/31/2004

639 Responsibility Amount
Start: 10/31/2004

640 Sales Tax Amount
Start: 10/31/2004

641 Service Adjudication or Payment Date
Start: 10/31/2004

642 Service Authorization Exception Code
Start: 10/31/2004

643 Service Line Paid Amount
Start: 10/31/2004

644 Service Line Rate
Start: 10/31/2004

645 Service Tax Amount
Start: 10/31/2004

646 Ship, Delivery or Calendar Pattern Code
Start: 10/31/2004

647 Shipped Date
Start: 10/31/2004

648 Similar Illness or Symptom Date
Start: 10/31/2004

649 Skilled Nursing Facility Indicator
Start: 10/31/2004

650 Special Program Indicator
Start: 10/31/2004

651 State Industrial Accident Provider Number
Start: 10/31/2004

652 Terms Discount Percentage
Start: 10/31/2004

653 Test Performed Date
Start: 10/31/2004

654 Total Denied Charge Amount
Start: 10/31/2004

655 Total Medicare Paid Amount
Start: 10/31/2004

656 Total Visits Projected This Certification Count
Start: 10/31/2004

657 Total Visits Rendered Count
Start: 10/31/2004

658 Treatment Code
Start: 10/31/2004

659 Unit or Basis for Measurement Code
Start: 10/31/2004

660 Universal Product Number
Start: 10/31/2004

661 Visits Prior to Recertification Date Count CR702
Start: 10/31/2004

662 X-ray Availability Indicator
Start: 10/31/2004

663 Entity's Group Name
Start: 10/31/2004

664 Orthodontic Banding Date
Start: 10/31/2004

665 Surgery Date
Start: 10/31/2004

666 Surgical Procedure Code
Start: 10/31/2004

667 Real-Time requests not supported by the information holder, do not resubmit
Start: 02/28/2005

668 Missing Endodontics treatment history and prognosis
Start: 06/30/2005

669 Dental service narrative needed.
Start: 10/31/2005

670 Funds applied from a consumer spending account such as consumer directed/driven

health plan (CDHP), Health savings account (H S A) and or other similar accounts
Start: 06/30/2006 | Last Modified: 02/28/2007

671 Funds may be available from a consumer spending account such as consumer directed/driven

health plan (CDHP), Health savings account (H S A) and or other similar accounts
Start: 06/30/2006 | Last Modified: 02/28/2007

672 Other Payer's payment information is out of balance
Start: 10/31/2006

673 Patient Reason for Visit
Start: 10/31/2006

674 Authorization exceeded
Start: 10/31/2006

675 Facility admission through discharge dates
Start: 10/31/2006

676 Entity possibly compensated by facility
Start: 10/31/2006

677 Entity not affiliated
Start: 10/31/2006

678 Revenue code and patient gender mismatch
Start: 10/31/2006

679 Submit newborn services on mother's claim
Start: 10/31/2006

680 Entity's Country
Start: 10/31/2006

681 Claim currency not supported
Start: 10/31/2006

682 Cosmetic procedure
Start: 02/28/2007

683 Awaiting Associated Hospital Claims
Start: 02/28/2007

684 Rejected. Syntax error noted for this claim/service/inquiry. See Functional or Implementation

Acknowledgement for details. (Note: Only for use to reject claims or status requests in

transactions that were 'accepted with errors' on a 997 or 999 Acknowledgement.)
Start: 11/05/2007

685 Claim could not complete adjudication in real time. Claim will continue processing in a batch

mode. Do not resubmit.
Start: 01/27/2008

686 The claim/ encounter has completed the adjudication cycle and the entire claim has been voided
Start: 01/27/2008

687 Claim estimation cannot be completed in real time. Do not resubmit.
Start: 01/27/2008

688 Present on Admission Indicator for reported diagnosis code(s).
Start: 01/27/2008

689 Entity was unable to respond within the expected time frame.
Start: 06/01/2008

690 Multiple claims or estimate requests cannot be processed in real time.
Start: 06/01/2008

691 Multiple claim status requests cannot be processed in real time.
Start: 06/01/2008

692 Contracted funding agreement-Subscriber is employed by the provider of services
Start: 09/21/2008

693 Amount must be greater than or equal to zero. Note: At least one other status code is required

to identify which amount element is in error.
Start: 01/25/2009

694 Amount must not be equal to zero. Note: At least one other status code is required to identify

which amount element is in error.
Start: 01/25/2009

695 Entity's Country Subdivision Code.
Start: 01/25/2009

696 Claim Adjustment Group Code.
Start: 01/25/2009

697 Invalid Decimal Precision. Note: At least one other status code is required to identify the data

element in error.
Start: 07/01/2009

698 Form Type Identification
Start: 07/01/2009

699 Question/Response from Supporting Documentation Form
Start: 07/01/2009

700 ICD10. Note: At least one other status code is required to identify the related procedure code

or diagnosis code.
Start: 07/01/2009

701 Initial Treatment Date
Start: 07/01/2009

APPENDIX E: Patient status Codes (Discharge status Codes)

A patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter (this could be a visit or an actual inpatient stay) or at the time end of a billing cycle (the ‘through' date of a claim). The Centers for Medicare & Medicaid Services (CMS) requires patient discharge status codes for:

Hospital Inpatient Claims (type of bills (TOBs) 11X and 12X);

Skilled Nursing Claims (TOBs 18X, 21X, 22X and 23X);

Outpatient Hospital Services (TOBs 13X, 14X, 71X, 73X, 74X, 75X, 76X and 85X); and

All Hospice and Home Health Claims (TOBs 32X, 33X, 34X, 81X and 82X).

It is important to select the correct patient discharge status code, and in cases in which two or more patient discharge status codes apply, you should code the highest level of care known. Omitting a code or submitting a claim with an incorrect code is a claim billing error and could result in your claim being rejected or your claim being cancelled and payment being taken back. Applying the correct code will help assure that you receive prompt and correct payment.

Identifying the appropriate Patient discharge status Code can sometimes be confusing, so be sure to read the Frequently Asked Questions (FAQ) Section at the end of this article for further guidance.

Patient Status codes and Their Appropriate Use

The following describes patient discharge status codes and provides details regarding their appropriate use:

01- Discharge to Home or Self Care (Routine Discharge)

This code includes discharge to home; jail or law enforcement; home on oxygen if DME only; any other DME only; group home, foster care, and other residential care arrangements; outpatient programs, such as partial hospitalization or outpatient chemical dependency programs; assisted living facilities that are not state-designated.

02 - Discharged/Transferred to a Short-term General Hospital for Inpatient Care

This patient discharge status code should be used when the patient is discharged or transferred to a short-term acute care hospital. Discharges or transfers to long-term care hospitals should be coded with Patient discharge status Code 63.

03 - Discharged/Transferred to a Skilled Nursing Facility (SNF) with Medicare Certification in Anticipation of Skilled Care.

This code indicates that the patient is discharged/transferred to a Medicare certified nursing facility in anticipation of skilled care. For hospitals with an approved swing bed arrangement, use Code 61- Swing Bed.

This code should be used regardless of whether or not the patient has skilled benefit days and regardless of whether the transferring hospital anticipates that this SNF stay will be covered by Medicare. For reporting other discharges/transfers to nursing facilities see codes 04 and 64.

Code 03 should not be used if:

The patient is admitted to a non-Medicare certified area.

04 - Discharged/Transferred to an Intermediate Care Facility (ICF)

Patient discharge status code 04 is typically defined at the state level for specifically designated intermediate care facilities. It is also used:

To designate patients that are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification, or

For discharges/transfers to state designated Assisted Living Facilities.

05 - Discharged/Transferred to another Type of Health Care Institution Not Defined Elsewhere in This Code List

Cancer hospitals excluded from Medicare PPS and children’s hospitals are examples of such other types of health care institutions.

NEW DEFINITION FOR PATIENT DISCHARGE STATUS CODE 05- Effective, per NUBC, on April 1, 2008

05 - Discharged/Transferred to a Designated Cancer Center or Children’s Hospital

Usage Note: Transfers to non-designated cancer hospitals should use Code 02. A list of (National Cancer Institute) Designated Cancer Centers can be found at http://cancercenters.cancer.gov/cancer_centers/cancer-centers-names.html on the Internet.

06 - Discharged/Transferred to Home under Care of Organized Home Health Service Organization in Anticipation of Covered Skilled Care

This code should be reported when a patient is:

Discharged/transferred to home with a written plan of care for home care services (tailored to the patient’s medical needs) -- whether home attendant, nursing aides, certified attendants, etc.

Discharged/transferred to a foster care facility with home care; and

Discharged to home under a home health agency with DME.

This code should not be used for home health services provided by a:

DME supplier or Home IV provider for home IV services.

07 - Left against Medical Advice or Discontinued Care

The important thing to remember about this patient discharge status code is that it is to be used when a patient leaves against medical advice or the care is discontinued. According to the NUBC, discontinued services may include:

Patients who leave before triage, or are triaged and leave without being seen by a physician; or

Patients who move without notice, and the home health agency is unable to complete the plan of care.

08 - Reserved for National Assignment

This patient discharge status code is reserved for national assignment. ML

09 - Admitted as an Inpatient to this Hospital

This code is for use only on Medicare outpatient claims, and it applies only to those Medicare outpatient services that begin greater than three days prior to an admission.

10-19 - Reserved for National Assignment

These patient discharge status codes are reserved for national assignment.

20 - Expired

This code is used only when the patient dies.

21-29 - Reserved for National Assignment

These patient discharge status codes are reserved for national assignment.

30 - Still Patient or Expected to Return for Outpatient Services

This code is used when the patient is still within the same facility and is typically used when billing for leave of absence days or interim bills. It can be used for both inpatient or outpatient claims,

It is used for inpatient claims when billing for leave of absence days or interim billing (i.e., the length of stay is longer than 60 days).

On outpatient claims, the primary method to identify that the patient is still receiving care is the bill type frequency code (e.g., Frequency Code 3: Interim - Continuing Claim).

31-39 - Reserved for National Assignment

These patient discharge status codes are reserved for national assignment.

Hospice Patient discharge status Codes - Hospice Claims Only (TOBs: 81X & 82X)

The following patient discharge status codes should only be used when submitting hospice claims:

40 - Expired at Home; This code is for use only on Medicare and TRICARE claims for hospice care.

41 - Expired in a Medical Facility, such as a Hospital, Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), or Free-standing Hospice; and

42 - Expired - Place Unknown; This code is for use only on Medicare and TRICARE claims for hospice care

43 - Discharged/Transferred to a Federal Hospital

This code applies to discharges and transfers to a government operated health care facility including:

Department of Defense hospitals;Veteran's Administration hospitals; or Veteran's Administration nursing facilities.

This patient discharge status code should be used whenever the destination at discharge is a federal health care facility, whether the patient resides there or not.

The NUBC has also clarified that this code should also be used when a patient is transferred to an inpatient psychiatric unit of a Veterans Administration (VA) hospital.

44-49 Reserved for National Assignment

These patient discharge status codes are reserved for national assignment.

50 and 51 - Discharged/Transferred to a Hospice

These two patient discharge status codes are used to identify when a patient is discharged or transferred to hospice care.

The level of care that will be provided by the hospice upon discharge is essential to determining the proper code to use. NUBC clarified the following Hospice Levels of Care:

Routine or Continuous Home Care. Patient discharge status code “50: Hospice home” should be used if the patient went to his/her own home or an alternative setting that is the patient’s “home,” such as a nursing facility, and will receive in-home hospice services.

General Inpatient Care. Patient discharge status code “51 Hospice medical facility” should be used if the patient went to an inpatient facility that is qualified and the patient is to receive the general inpatient hospice level of care.

Inpatient Respite. Patient discharge status code “51 Hospice medical facility” should be used if the patient went to a facility that is qualified and the patient is receiving hospice inpatient respite level of care. Unless a patient has already been admitted to/accepted by a hospice, level of care can not be determined. Therefore, it is recommended that, if a patient is going home or to an institutional setting with a hospice “referral only,” (without having already been accepted for hospice care by a hospice organization) the patient discharge status code should simply reflect the site to which the patient was discharged, not hospice (i.e. 01: home or self care, or 04: an intermediate care nursing facility, assuming it is not a Medicare SNF admission).

Additional Guidance on Use of Patient discharge status Code 50 or 51:

Patient discharge status Code 50 should be used if the patient went to his/her own home or an alternative setting that is the patient’s “home,” such as a nursing facility, and will receive in-home hospice services.

Patient discharge status Code 51 should be used when a patient is: M

• Discharged from acute hospital care but remains at the same hospital under hospice care,

• Transferred from an inpatient acute care hospital to a Medicare-certified SNF under the following conditions:

o The patient has elected the hospice benefit and will be receiving hospice care under arrangement with a hospice organization; the patient is receiving residential care only.

o The patient does not qualify for skilled level of care outside the hospice benefit for conditions unrelated to the terminal illness.

o Admitted from home (a private residence) to an acute setting. Upon discharge, the patient is transferred as a new nursing home placement to a designated hospice unit/bed.

52-60 - Reserved for National Assignment

These patient discharge status codes are reserved for national assignment.

61 - Discharged/Transferred to a Hospital-based Medicare Approved Swing Bed

This code is used for reporting patients discharged/transferred to a SNF level of care within the hospital’s approved swing bed arrangement.

When a patient is discharged from an acute hospital to a Critical Access Hospital (CAH) swing bed, use Patient discharge status Code 61. Swing beds are not part of the post acute care transfer policy

62 - Discharged/Transferred to an Inpatient Rehabilitation Facility Including Distinct Part Units of a Hospital

Inpatient rehabilitation facilities (or designated units) are those facilities that meet a specific requirement that 75% of their patients require intensive rehabilitative services for the treatment of certain medical conditions. This code should be used when a patient is transferred to a facility or designated unit that meets this qualification.

63 - Discharged/Transferred to Long Term Care Hospitals

This code is for hospitals that meet the Medicare criteria for LTCH certification as follows: Long term care hospitals are facilities that provide acute inpatient care with an average length of stay of 25 days or greater. This code should be used when transferring a patient to a long term care hospital. If you are not sure whether a facility is a long term care hospital or a short term care hospital, you should contact the facility to verify their facility type before assigning a patient discharge status code. M

64 - Discharged/Transferred to a Nursing Facility Certified Under Medicaid but not Certified Under Medicare

Nursing facilities may elect to certify only a portion of their beds under Medicare, and some nursing facilities choose to certify all of their beds under Medicare. Still others elect not to certify any of their beds under Medicare. When a patient is transferred to a nursing facility that has no Medicare certified beds, this code should be used. If any beds at the facility are Medicare certified, then the provider should use either Patient discharge status Code 03 or 04, depending on:

The level of care the patient is receiving; and Whether the bed is Medicare certified or not.

65 - Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital

This code should be used when a patient is transferred to an inpatient psychiatric unit or inpatient psychiatric designated unit.

Note: This code should not be used when a patient is transferred to an inpatient psychiatric unit of a federal hospital (e.g. Veterans Administration Hospitals). In this case, see Patient discharge status Code 43.

66 - Discharged/Transferred to a Critical Access Hospital (CAH)

Patient discharge status Code 66 is used to identify a transfer to a critical access hospital (CAH) for inpatient care. Providers will need to establish a process for identifying whether a hospital is paid under the prospective payment system (PPS) or whether the facility is designated as a CAH.

Note: Discharges or transfers to a critical access hospital (CAH) swing bed should still be coded with Patient discharge status Code 61.

67-69 - Reserved for National Assignment

These patient discharge status codes are reserved for national assignment.

NEW PATIENT DISCHARGE STATUS CODE 70 – Per NUBC, Effective April 1, 2008:

70 – Discharged/transferred to another Type of Health Care Institution not Defined Elsewhere in this Code List

New patient discharge status code 70 was created in order for providers to be able to indicate discharges/transfers to another type of health care institution not defined elsewhere in the code list. This code is effective for use by providers for discharges/to dates on or after April 1, 2008. (See Code 05)

71-99 - Reserved for National Assignment

These patient discharge status codes are reserved for national assignment. M

Patient Discharge Status Codes Affected by the Hospital Transfer Policies for Inpatient PPS and IRF PPS

The IPPS Acute to Acute Transfer policy applies to transfers coded with patient discharge status code 02 and applies to ALL DRGs and when the length of stay is less than the average length of stay for the DRG.

Under Medicare’s Post Acute Care Transfer policy (42 CFR 412.4), a discharge of a hospital inpatient is considered to be a post acute care transfer when the patient’s discharge is assigned to one of the qualifying diagnosis-related groups (DRGs), and the discharge is made under any of the following circumstances:

To a hospital or distinct part hospital unit excluded from the inpatient prospective payment system (IPPS) (includes: Inpatient Rehabilitation Facilities, Long Term Care Hospitals, psychiatric hospitals, cancer hospitals and children’s hospitals);

To a skilled nursing facility (not swing beds); and

To home under a written plan of care for the provision of home health services from a home health agency and those services begin within 3 days after the date of discharge.

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