Transformed - Medicaid Statistical Information System (T-MSIS)

Medicaid Statistical Information System (MSIS) and the Transformed - Medicaid Statistical Information System (T-MSIS) (CMS-R-284)

2 - T-MSIS V2_0 Data Dictionary Appendices - 2015-11-24

Transformed - Medicaid Statistical Information System (T-MSIS)

OMB: 0938-0345

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T-MSIS Data Dictionary Appendices

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Version: Nov15v2.0

T-MSIS Data Dictionary Appendices


Contents

Appendix A: Valid Values 10

Managed Care Plan Information File Valid Values 11

ACCREDITATION-ORGANIZATION 12

CORE-BASED-STATISTICAL-AREA-CODE 13

FILE-ENCODING-SPECIFICATION 14

FILE-NAME 15

FILE-STATUS-INDICATOR 16

MANAGED-CARE-ADDR-TYPE 17

MANAGED-CARE-COUNTY 18

MANAGED-CARE-PLAN-POP 19

MANAGED-CARE-PLAN-TYPE 20

MANAGED-CARE-PROFIT-STATUS 21

MANAGED-CARE-PROGRAM 22

MANAGED-CARE-SERVICE-AREA 23

MANAGED-CARE-SERVICE-AREA-NAME 24

MANAGED-CARE-STATE 25

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE 26

OPERATING-AUTHORITY 27

RECORD-ID 28

REIMBURSEMENT-ARRANGEMENT 29

SUBMISSION-TRANSACTION-TYPE 30

SUBMITTING-STATE 31

Provider File Valid Values 32

ACCEPTING-NEW-PATIENTS-IND 33

ADDR-BORDER-STATE-IND 34

ADDR-COUNTY 35

ADDR-STATE 36

ADDR-TYPE 37

AFFILIATED-PROGRAM-TYPE 38

BED-TYPE-CODE 39

FACILITY-GROUP-INDIVIDUAL-CODE 40

FILE-ENCODING-SPECIFICATION 41

FILE-NAME 42

FILE-STATUS-INDICATOR 43

LICENSE-TYPE 44

OWNERSHIP-CODE 45

PROV-CLASSIFICATION-TYPE 46

PROV-ENROLLMENT-METHOD 56

PROV-IDENTIFIER-TYPE 57

PROV-MEDICAID-ENROLLMENT-STATUS-CODE 58

PROV-PROFIT-STATUS 60

RECORD-ID 61

SEX 62

STATE-PLAN-ENROLLMENT 63

SUBMISSION-TRANSACTION-TYPE 64

SUBMITTING-STATE 65

TEACHING-IND 66

Eligible File Valid Values 67

1115A-DEMONSTRATION-IND 68

ADDR-TYPE 69

CERTIFIED-AMERICAN-INDIAN/ALASKAN-NATIVE-INDICATOR 70

CHIP-CODE 71

CITIZENSHIP-IND 72

CITIZENSHIP-VERIFICATION-FLAG 73

CONCEPTION-TO-BIRTH-IND 74

DISABILITY-TYPE-CODE 75

DUAL-ELIGIBLE-CODE 76

ELIGIBILITY-CHANGE-REASON 77

ELIGIBILITY-GROUP 78

ELIGIBLE-COUNTY-CODE 79

ELIGIBLE-STATE 80

ENROLLMENT-TYPE 81

ETHNICITY-CODE 82

FILE-ENCODING-SPECIFICATION 83

FILE-NAME 84

FILE-STATUS-INDICATOR 85

HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE 86

HEALTH-HOME-CHRONIC-CONDITION 87

HOUSEHOLD-SIZE 88

IMMIGRATION-STATUS 89

IMMIGRATION-VERIFICATION-FLAG 90

INCOME-CODE 91

LEVEL-OF-CARE-STATUS 92

LOCKIN-PROV-TYPE 93

LTSS-LEVEL-CARE 94

MAINTENANCE-ASSISTANCE-STATUS 95

MANAGED-CARE-PLAN-TYPE 96

MARITAL-STATUS 97

MEDICAID-BASIS-OF-ELIGIBILITY 98

MFP-LIVES-WITH-FAMILY 99

MFP-QUALIFIED-INSTITUTION 100

MFP-QUALIFIED-RESIDENCE 101

MFP-REASON-PARTICIPATION-ENDED 102

MFP-REINSTITUTIONALIZED-REASON 103

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE 104

PREGNANCY-IND 105

PRIMARY-LANGUAGE-CODE 106

PRIMARY-LANGUAGE-ENGL-PROF-CODE 107

RACE 108

RECORD-ID 109

RESTRICTED-BENEFITS-CODE 110

SEX 111

SSDI-IND 112

SSI-STATE-SUPPLEMENT-STATUS-CODE 113

SSI-STATUS 114

SSN-INDICATOR 115

SSN-VERIFICATION-FLAG 116

STATE-PLAN-OPTION-TYPE 117

SUBMISSION-TRANSACTION-TYPE 118

SUBMITTING-STATE 119

TANF-CASH-CODE 120

VETERAN-IND 121

WAIVER-TYPE 122

Third-party Liability File Valid Values 122

COVERAGE-TYPE 124

FILE-ENCODING-SPECIFICATION 125

FILE-NAME 126

FILE-STATUS-INDICATOR 127

INSURANCE-CARRIER-STATE 128

INSURANCE-PLAN-TYPE 129

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE 130

POLICY-OWNER-CODE 131

RECORD-ID 132

SSN-INDICATOR 133

SUBMISSION-TRANSACTION-TYPE 134

SUBMITTING-STATE 135

TPL-ENTITY-ADDR-TYPE 136

TPL-HEALTH-INSURANCE-COVERAGE-IND 137

TPL-OTHER-COVERAGE-IND 138

TYPE-OF-OTHER-THIRD-PARTY-LIABILITY 139

Claims Files Valid Values 140

1115A-DEMONSTRATION-IND 141

ADJUSTMENT-IND 142

ADJUSTMENT-REASON-CODE 143

ADMISSION-HOUR 144

ADMISSION-TYPE 145

ADMITTING-DIAGNOSIS-CODE 146

ADMITTING-DIAGNOSIS-CODE-FLAG 147

ADMITTING-PROV-NPI-NUM 148

ADMITTING-PROV-SPECIALTY 149

ADMITTING-PROV-TAXONOMY 150

ADMITTING-PROV-TYPE 151

ALLOWED-CHARGE-SRC 152

BENEFIT-TYPE 153

BILLING-PROV-NPI-NUM 159

BILLING-PROV-SPECIALTY 160

BILLING-PROV-TAXONOMY 161

BILLING-PROV-TYPE 162

BILLING-UNIT 163

BORDER-STATE-IND 164

BRAND-GENERIC-IND 165

CLAIM-DENIED-INDICATOR 166

CLAIM-LINE-STATUS 167

CLAIM-PYMT-REM-CODE-1 to CLAIM-PYMT-REM-CODE-4 168

CLAIM-STATUS 169

CLAIM-STATUS-CATEGORY 170

CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT 171

COMPOUND-DOSAGE-FORM 172

COMPOUND-DRUG-IND 173

COPAY-WAIVED-IND 174

CROSSOVER-INDICATOR 175

DESTINATION-STATE 176

DIAGNOSIS-CODE-1 to DIAGNOSIS-CODE-12 177

DIAGNOSIS-CODE-FLAG-1 to DIAGNOSIS-CODE-FLAG-12 178

DIAGNOSIS-POA-FLAG-1 to DIAGNOSIS-POA-FLAG-12 179

DISCHARGE-HOUR 180

DISPENSING-PRESCRIPTION-DRUG-PROV-NPI 181

DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY 182

DRG-DESCRIPTION 183

DRUG-UTILIZATION-CODE 184

FILE-ENCODING-SPECIFICATION 187

FILE-NAME 188

FILE-STATUS-INDICATOR 189

FIXED-PAYMENT-IND 190

FORCED-CLAIM-IND 191

FUNDING-CODE 192

FUNDING-SOURCE-NONFEDERAL-SHARE 193

HCBS-SERVICE-CODE 194

HCBS-TAXONOMY 195

HCPCS-RATE 197

HEALTH-CARE-ACQUIRED-CONDITION-IND 198

HEALTH-HOME-ENTITY-NAME 199

HEALTH-HOME-PROVIDER-NPI 200

HEALTH-HOME-PROV-IND 201

IMMUNIZATION-TYPE 202

LINE-ADJUSTMENT-IND 203

LINE-ADJUSTMENT-REASON-CODE 204

MEDICARE-COMB-DED-IND 205

MEDICARE-REIM-TYPE 206

NEW-REFILL-IND 207

NDC-UNIT-OF-MEASURE 208

OCCURRENCE-CODE-01 to OCCURRENCE-CODE-10 209

OPERATING-PROV-NPI-NUM 210

OPERATING-PROV-TAXONOMY 211

ORIGINATION-STATE 212

OTHER-INSURANCE-IND 213

OTHER-TPL-COLLECTION 214

OUTLIER-CODE 215

PATIENT-STATUS 216

PAYMENT-LEVEL-IND 217

PLACE-OF-SERVICE 218

PRESCRIBING-PROV-SPECIALTY 219

PRESCRIBING-PROV-TAXONOMY 220

PRESCRIBING-PROV-TYPE 221

PROCEDURE-CODE 1 TO PROCEDURE-CODE-6 222

PROCEDURE-CODE-FLAG-1 - PROCEDURE-CODE-FLAG-6 223

PROGRAM-TYPE 224

PROV-FACILITY-TYPE 225

REBATE-ELIGIBLE-INDICATOR 226

RECORD-ID 227

REFERRING-PROV-NPI-NUMBER 228

REFERRING-PROV-SPECIALTY 229

REFERRING-PROV-TAXONOMY 230

REFERRING-PROV-TYPE 231

SELF-DIRECTION-TYPE 232

SERVICE-TRACKING-TYPE 233

SERVICING-PROV-NPI-NUM 234

SERVICING-PROV-SPECIALTY 235

SERVICING-PROV-TAXONOMY 236

SOURCE-LOCATION 237

SPLIT-CLAIM-IND 238

SSN-INDICATOR 239

SUBMISSION-TRANSACTION-TYPE 240

SUBMITTING-STATE 241

TOOTH-DESIGNATION-SYSTEM 242

TOOTH-NUM 243

TOOTH-QUAD-CODE 244

TOOTH-SURFACE-CODE 245

TYPE-OF-BILL 246

TYPE-OF-CLAIM 248

TYPE-OF-HOSPITAL 249

TYPE-OF-SERVICE 250

UNDER-DIRECTION-OF-PROV-NPI 255

UNDER-DIRECTION-OF-PROV-TAXONOMY 256

UNDER-SUPERVISION-OF-PROV-NPI 257

UNDER-SUPERVISION-OF-PROV-TAXONOMY 258

UNIT-OF-MEASURE 259

WAIVER-TYPE 260

XIX-MBESCBES-CATEGORY-OF-SERVICE 261

XXI-MBESCBES-CATEGORY-OF-SERVICE 262

Appendix B: Home and Community-Based Services (HCBS) Taxonomy 263

Appendix C: Comprehensive Eligibility Crosswalk 280

Appendix D: Types of Service (TOS) Reference 293

Appendix E: Program Type Reference 303

Appendix F: Eligibility Group Table 310

Appendix G: ISO 639 Language Codes Reference 323

Appendix H: Benefit Types 330

Appendix I: MBES CBES Category of Service Line Definitions for the 64.9 Base Form 357

Appendix J: MBES CBES Category of Service Line Definitions for the 21 Form 387

Appendix K: Crosswalk of T-MSIS to MSIS Type of Service Values 392

Appendix L: Crosswalk of Washington Publishing Company Provider Taxonomy Codes to Provider Facility Type Categories 397

Appendix M: Crosswalk of T-MSIS, MSIS and MMA Duel Eligible Code 460

Appendix N: Coding Specific Data Elements for Claim Files 462

Appendix O: TYPE-OF-SERVICE Hierarchy Table 464

Appendix P: CMS Guidance Library 465

Appendix P.01: Submitting Adjustment Claims to TMSIS 466

Appendix P.02: Reporting Financial Transactions in T-MSIS - How to populate T-MSIS claim files when reporting non-claim expenditures and recoupments 472

Appendix P.03: Full File Replacement Submissions for Non-Claim T-MSIS File revised 478

Appendix P.04: Non-Claim Full File Refreshes - Amount of History Required 482

Appendix P.05: Populating Qualifier Fields and Their Associated Value Fields 485

Appendix P.06: IIFI (Inter/Intra-File Indices) 493

Appendix P.07: Finding Provider Roles on STD Transactions 516

Appendix Q: Terms and Abbreviations 9



Appendix A: Valid Values

Managed Care Plan Information File Valid Values



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Managed Care Plan Information File Valid Values

ACCREDITATION-ORGANIZATION

Code

Description

01

National committee for quality assurance – excellent

02

National committee for quality assurance – commendable

03

National committee for quality assurance – provisional

04

National committee for quality assurance – new plan no longer a valid accreditation level

05

URAC – full

06

URAC – conditional

07

URAC – provisional

08

Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) – 3 years

09

Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) – 1 year - no longer valid accreditation level

10

Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) – 6 months - no longer valid accreditation level

11

Not accredited

12

Other

13

National committee for quality assurance-- accredited

14

National committee for quality assurance - interim

15

National committee for quality assurance - denied



Additional accreditation information can be found at:


NCQA

http://www.ncqa.org/Programs/Accreditation/HealthPlanHP/AccreditationLevels.aspx



AAAHC

http://www.aaahc.org/en/accreditation/General-information/policies/terms-of-accreditation/





CORE-BASED-STATISTICAL-AREA-CODE

Code

Description

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.





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Managed Care Plan Information File Valid Values



FILE-ENCODING-SPECIFICATION

Code

Description

FIX

The file follows a fixed length format.

PSV

The file follows a pipe-delimited format.





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Managed Care Plan Information File Valid Values



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Managed Care Plan Information File Valid Values

FILE-NAME

Code

Description

MNGDCARE

Managed Care Plan Information File





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Managed Care Plan Information File Valid Values

FILE-STATUS-INDICATOR

Code

Description

P

Production File

T

Test File





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Managed Care Plan Information File Valid Values

MANAGED-CARE-ADDR-TYPE

Code

Description

1

MCO’s corporate address and contact information

2

MCO’s mailing address

3

MCO’s service location address

4

MCO’s Billing address and contact information

5

CEO’s address and contact information

6

CFO’s address and contact information

7

Other







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Managed Care Plan Information File Valid Values

MANAGED-CARE-COUNTY


http://www.census.gov/geo/reference/codes/cou.html







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Managed Care Plan Information File Valid Values

MANAGED-CARE-PLAN-POP

See Appendix F: Eligibility Group Table for listing of valid values.





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Managed Care Plan Information File Valid Values

MANAGED-CARE-PLAN-TYPE

Code

Description

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

13

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

14

Dental PAHP

15

Transportation PAHP

16

Disease Management PAHP

17

PACE

18

Pharmacy PAHP

99

Unknown

60

Accountable Care Organization

70

Health/Medical Home

80

Integrated Care For Dual Eligibles



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Managed Care Plan Information File Valid Values

MANAGED-CARE-PROFIT-STATUS

01

501(C)(3) NON-PROFIT

02

FOR-PROFIT, CLOSELY HELD

03

FOR-PROFIT, PUBLICLY TRADED

04

OTHER

99

Unknown



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Managed Care Plan Information File Valid Values

MANAGED-CARE-PROGRAM

1

Medicaid State Plan

2

CHIP State Plan

3

Both Medicaid and CHIP



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Managed Care Plan Information File Valid Values

MANAGED-CARE-SERVICE-AREA

1

Statewide- The managed care entity provides services to beneficiaries throughout the entire state.

2

County- The managed care entity provides services to beneficiaries in specified counties.

3

City- The managed care entity provides services to beneficiaries in specified cities.

4

Region- The managed care entity provides services to beneficiaries in specified regions, not defined by individual counties within the state (“region” is state-defined).

5

Zip Code- The managed care entity program provides services to beneficiaries in specified zip codes.

6

Other- The managed care entity provides services to beneficiaries in "other" area(s), not Statewide, County, City, or Region.



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Managed Care Plan Information File Valid Values

MANAGED-CARE-SERVICE-AREA-NAME


http://www.census.gov/geo/reference/ansi.html





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Managed Care Plan Information File Valid Values

MANAGED-CARE-STATE


http://www.census.gov/geo/reference/ansi_statetables.html



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Managed Care Plan Information File Valid Values

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

1

Controlling Health Plan (CHP) ID – the national health plan identifier of a health plan that either controls its own business activities, actions, or policies, or is controlled by an entity that is not a health plan and exercises sufficient control over the subhealth plan(s) under it so as to direct its own business activities, actions, or policies, as well as those of any subhealth plans under it. Every health plan will have a CHP.

2

Subhealth Plan (SHP) ID – the national health plan identifier of a health plan whose business activities, actions, or policies are directed by a controlling health plan. All subhealth HPIDs should be reported.

Note: While all health plans will have a CHP, not all plans will have one or more SHPs.

3

Other Entity Identifier (OEID) – a national identifier for entities that are not health plans, health care providers, or individuals (as defined in 45 CFR 160.103), but that need to be identified in standard transactions (including, for example, third party administrators, transaction vendors, clearinghouses, and other payers). Other entities are not required to obtain an OEID, but they could obtain and use one if they need to be identified in covered transactions.





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Managed Care Plan Information File Valid Values

OPERATING-AUTHORITY

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) waiver program – waivers of most provisions of Section 1902 of the Social Security Act in order to limit beneficiaries’ freedom of choice of provider; selectively contract with providers; or provide additional services to beneficiaries (State may include BBA special populations)

03

1932(a) state plan option to use managed care for MCO and PCCM programs – mandatory managed care programs implemented through the state plan (State must exclude or permit voluntary enrollment of specific populations)

04

1915(a) voluntary managed care program – an MCO managed care program in which enrollment is voluntary and therefore does not require a waiver.


05

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.

06

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

07

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.

08

PACE – program that provides pre-paid, capitated comprehensive, health care services to the frail elderly.

09

1905(t) voluntary PCCM program – A PCCM managed care program in which enrollment is voluntary and therefore does not require a waiver.

10

1937benchmark benefit program—programs to provide benefits that differ from Medicaid state plan benefits using managed care and implemented through the state plan.

11

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

12

Concurrent 1915(b)/1915(i) HCBS state plan services - the optional 1915(i) state plan Home and Community-Based Services (HCBS) benefit operated in conjunction with a 1915(b) managed care waiver program.

13

Concurrent 1915(a)/ 1915(i) HCBS state plan services - the optional 1915(i) state plan Home and Community-Based Services (HCBS) benefit operated in conjunction with a 1915(a) voluntary managed care program.

14

Concurrent 1932(a)/ 1915(i) HCBS state plan services - the optional 1915(i) state plan Home and Community-Based Services (HCBS) benefit operated in conjunction with a 1932(a) managed care state plan option.

15

1945 Health Homes.





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Managed Care Plan Information File Valid Values

RECORD-ID

MCR00001

FILE-HEADER-RECORD-MANAGED-CARE

MCR00002

MANAGED-CARE-MAIN

MCR00003

MANAGED-CARE-LOCATION-AND-CONTACT-INFO

MCR00004

MANAGED-CARE-SERVICE-AREA

MCR00005

MANAGED-CARE-OPERATING-AUTHORITY

MCR00006

MANAGED-CARE-PLAN-POPULATION-ENROLLED

MCR00007

MANAGED-CARE-ACCREDITATION-ORGANIZATION

MCR00008

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO

MCR00009

CHPID-SHPID-RELATIONSHIP





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Managed Care Plan Information File Valid Values

REIMBURSEMENT-ARRANGEMENT

01

Risk-based Capitation, no incentives or risk-sharing

02

Risk-based Capitation with Incentive Arrangements

03

Risk-based Capitation with other risk-sharing Arrangements

04

Non-Risk Capitation

05

Fee-For-Service

06

Primary Care Case Management Payment

07

Other

08

Primary Care Case Management Payment plus Fee-For-Service

88

Not Applicable

99

Unknown



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Managed Care Plan Information File Valid Values

SUBMISSION-TRANSACTION-TYPE

C

Create File—a file that contains a complete set of transactions/changes processed since the last Create file submission. States may submit only one valid Create file per reporting period and data file type.

R

Replacement File—a Replacement submission is a replacement of the month’s data. It will completely replace the immediate prior submission. If a later replacement entry is received, it will overwrite the previous replacement, as well as a prior Create or Update submission for the same data type and reporting period.

U

Update File—a file that contains T-MSIS record segments created in response to business rule rejects. Note: The records in an Update file are not generated as a result of a change processed in the state’s Medicaid or Medicaid-related systems during the current reporting month. These Update file record segments may be unchanged from the ones submitted previously for various reasons (for example, the state may be unable to process a change record in their Medicaid / Medicaid-related systems to correct the issue because the state is simply passing through to T-MSIS data that originated outside of the state’s systems).[1] Conversely, the records may be different from those previously submitted, but the change is the result of a fix whose root cause problem was an issue in the T-MSIS file-creation or replacement process at CMS. Regardless, the record was not generated from a change that occurred in the state’s source data.



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Managed Care Plan Information File Valid Values

SUBMITTING-STATE


http://www.census.gov/geo/reference/ansi_statetables.html


Provider File Valid Values



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Provider File Valid Values

ACCEPTING-NEW-PATIENTS-IND

0

No

1

Yes

8

N/A – The individual only practices as a member of a group.




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Provider File Valid Values

ADDR-BORDER-STATE-IND

Code

Description

0

No

1

Yes

8

N/A - State does not distinguish “border state providers”.





ADDR-COUNTY

http://www.census.gov/geo/reference/codes/cou.html





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Provider File Valid Values



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Provider File Valid Values

ADDR-STATE


http://www.census.gov/geo/reference/ansi_statetables.html





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Provider File Valid Values

ADDR-TYPE

1

Provider Billing

2

Provider Mailing

3

Provider Practice

4

Provider Service Location





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Provider File Valid Values

AFFILIATED-PROGRAM-TYPE

1

Health Plan (NHP-ID) – The value in the AFFILIATED-PROGRAM-ID data element contains the National Health Plan Identifier of health plan in which the provider is enrolled to provide services including through the state plan and a waiver.

2

Health Plan (state-assigned health plan ID) – The value in the AFFILIATED-PROGRAM-ID data element contains the state-assigned health plan Identifier of health plan in which the provider is enrolled to provide services including through the state plan and a waiver.

3

Waiver – The value in the AFFILIATED-PROGRAM-ID data element contains an identifier for the waiver in which a provider is allowed to deliver services to eligible beneficiaries.

4

Health Home Entity – The value in the AFFILIATED-PROGRAM-ID data element contains the name of the health home in which a provider is participating. The health home entity is responsible for providing health home services to the patient in conformance with the Health Home SPA. This is the name that the state uses to uniquely identify the health home team. This 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).

5

Other – The value in the AFFILIATED-PROGRAM-ID data element contains an identifier for something other than a health plan, waiver, or health home entity





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Provider File Valid Values

BED-TYPE-CODE



1

Intermediate Care Facility for the Intellectually Disabled

2

Inpatient

3

Nursing Facility

4

Title 18 Skilled Nursing Facility (T18 SNF)

8

Not Applicable





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Provider File Valid Values

FACILITY-GROUP-INDIVIDUAL-CODE

01

Facility – The entity identified by the associated SUBMITTING-STATE-PROV-ID is a facility.

02

Group – The entity identified by the associated SUBMITTING-STATE-PROV-ID is a group of individual practitioners.

03

Individual – The entity identified by the associated SUBMITTING-STATE-PROV-ID is an individual practitioner.





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Provider File Valid Values

FILE-ENCODING-SPECIFICATION

FIX

The file follows a fixed length format.

PSV

The file follows a pipe-delimited format.





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Provider File Valid Values

FILE-NAME

PROVIDER

Provider File





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Provider File Valid Values

FILE-STATUS-INDICATOR

P

Production file

T

Test file





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Provider File Valid Values

LICENSE-TYPE

1

State, county, or municipality professional or business license

2

DEA license

3

Professional society accreditation

4

CLIA accreditation

5

Other





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Provider File Valid Values

OWNERSHIP-CODE

01

Voluntary – Non-Profit – Religious Organizations

02

Voluntary – Non-Profit – Other

03

Voluntary – multiple owners

04

Proprietary – Individual

05

Proprietary – Corporation

06

Proprietary – Partnership

07

Proprietary – Other

08

Proprietary – multiple owners

09

Government – Federal

10

Government – State

11

Government – City

12

Government – County

13

Government – City-County

14

Government – Hospital District

15

Government – State and City/County

16

Government – other multiple owners

17

Voluntary /Proprietary

18

Proprietary/Government

19

Voluntary/Government

88

N/A – The individual only practices as part of a group, e.g., as an employee



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Provider File Valid Values



PROV-CLASSIFICATION-TYPE

1

Taxonomy code

2

Provider specialty code

3

Provider type code

4

Authorized category of service code





NOTE: The valid value code ‘47’ in the PROV-CLASSIFICATION-TYPE = 2 (Provider Specialty Code) can be used now.

47" = Independent Diagnostic Testing Facility (IDTF)”







































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Provider File Valid Values

If PROV-CLASSIFICATION-TYPE is 2 (Provider specialty code) then reference the following table for the appropriate PROV-CLASSIFICATION-CODE valid value

Code

Description

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

15

Speech Language Pathologist

16

Obstetrics/Gynecology

17

Hospice and Palliative Care

18

Ophthalmology

19

Oral Surgery (dentists only)

20

Orthopedic Surgery

21

Cardiac Electrophysiology

22

Pathology

23

Sports Medicine

24

Plastic and Reconstructive Surgery

25

Physical Medicine and Rehabilitation

26

Psychiatry

27

Geriatric Psychiatry

28

Colorectal Surgery (formerly proctology)

29

Pulmonary Disease

30

Diagnostic Radiology

31

Cardiac Rehabilitation & Intensive Cardiac Rehabilitation

32

Anesthesiologist Assistant

33

Thoracic Surgery

34

Urology

35

Chiropractic

36

Nuclear Medicine

37

Pediatric Medicine

38

Geriatric Medicine

39

Shape39

Provider File Valid Values

Nephrology

40

Hand Surgery

41

Optometry

42

Certified Nurse Midwife

43

Certified Registered Nurse Anesthetist (CRNA)

44

Infectious Disease

45

Mammography Center

46

Endocrinology

47

Independent Diagnostic Testing Facility (IDTF)

48

Podiatry

49

Ambulatory Surgical Center

50

Nurse Practitioner

51

Medical Supply Company with Orthitist

52

Medical Supply Company with Prosthetist

53

Medical Supply Company with Orthitist-Prosthetist

54

Other Medical Supply Company

55

Individual Certified Orthotist

56

Individual Certified Prosthetist

57

Individual Certified Orthitist-Prosthetist

58

Medical Supply Company with Pharmacist

59

Ambulance Service Provider

60

Public Health or Welfare Agency

61

Voluntary Health or Charitable Agency

62

Psychologist, Clinical

63

Portable X-Ray Supplier

64

Audiologist

65

Physical Therapist in Private Practice

66

Rheumatology

67

Occupational Therapist in Private Practice

68

Psychologist, Clinical

69

Clinical Laboratory

70

Single or Multispecialty Clinic or Group Practice

71

Registered Dietitian or Nutrition Professional

72

Pain Management

73

Mass Immunization Roster Biller

74

Radiation Therapy Center

75

Slide Preparation Facility

76

Peripheral Vascular Disease

77

Vascular Surgery

78

Cardiac Surgery

79

Addiction Medicine

80

Licensed Clinical Social Worker

81

Critical Care (Intensivists)

82

Hematology

83

Hematology/Oncology

84

Preventive Medicine

85

Maxillofacial Surgery

86

Neuropsychiatry

87

All Other Suppliers

89

Certified Clinical Nurse Specialist

90

Medical Oncology

91

Surgical Oncology

92

Radiation Oncology

93

Emergency Medicine

94

Interventional Radiology

95

Advance Diagnostic Imaging

96

Optician

97

Physician Assistant

98

Gynecological/Oncology

A0

Hospital-General

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

A9

Indian Health Service facility

B1

Oxygen supplier

B2

Pedorthic personnel

B3

Medical supply company with pedorthic personnel

B4

Rehabilitation Agency

B5

Ocularist

Shape40

Provider File Valid Values













Shape41

Provider File Valid Values

If PROV-CLASSIFICATION-TYPE is 3 (Provider type code) then reference the following table for the appropriate PROV-CLASSIFICATION-CODE valid value



PROV-CLASSIFICATION-TYPE = 3 (Provider Type Code)

Provider Type Code

Provider Type Description

01

Physician

02

Speech Language Pathologist

03

Oral Surgery (Dentist only)

04

Cardiac Rehabilitation and Intensive Cardiac Rehabilitation

05

Anesthesiology Assistant

06

Chiropractic

07

Optometry

08

Certified Nurse Midwife

09

Certified Registered Nurse Anesthetist (CRNA)

10

Mammography Center

11

Independent Diagnostic Testing Facility (IDTF)

12

Podiatry

13

Ambulatory Surgical Center

14

Nurse Practitioner

15

Medical Supply Company with Orthotist

16

Medical Supply Company with Prosthetist

17

Medical Supply Company with Orthotist-Prosthetist

18

Other Medical Supply Company

19

Individual Certified Orthotist

20

Individual Certified Prosthetist

21

Individual Certified Prosthetist-Orthotist

22

Medical Supply Company with Pharmacist

23

Ambulance Service Provider

24

Public Health or Welfare Agency

25

Voluntary Health or Charitable Agency

26

Psychologist, Clinical

27

Portable X-Ray Supplier

28

Audiologist

29

Physical Therapist in Private Practice

30

Occupational Therapist in Private Practice

31

Clinical Laboratory

32

Clinic or Group Practice

33

Registered Dietitian or Nutrition Professional

34

Mass Immunizer Roster Biller

35

Radiation Therapy Center

36

Slide Preparation Facility

37

Licensed Clinical Social Worker

38

Certified Clinical Nurse Specialist

39

Advance Diagnostic Imaging

40

Optician

41

Physician Assistant

42

Hospital-General

43

Skilled Nursing Facility

44

Intermediate Care Nursing Facility

45

Other Nursing Facility

46

Home Health Agency

47

Pharmacy

48

Medical Supply Company with Respiratory Therapist

49

Department Store

50

Grocery Store

51

Indian Health Service facility

52

Oxygen supplier

5t3

Pedorthic personnel

54

Medical supply company with pedorthic personnel

55

Rehabilitation Agency

56

Ocularist

57

All Other















Shape42

Provider File Valid Values

If PROV-CLASSIFICATION-TYPE is 4 (Authorized category of service code) then reference the following table for the appropriate PROV-CLASSIFICATION-CODE valid value

Code

Description

001

Inpatient hospital services, other than services in an institution for mental diseases

002

Outpatient hospital services

003

Rural health clinic services

004

Other ambulatory services furnished by a rural health clinic

005

Professional laboratory services

006

Technical laboratory services

007

Professional radiological services

008

Technical radiological services

009

Nursing facility services for individuals age 21 or older (other than services in an institution for mental disease)

010

Early and periodic screening and diagnosis and treatment (EPSDT) services

011

Family planning services and supplies for individuals of child-bearing age

012

Physicians' services

013

Medical and surgical services of a dentist

014

Outpatient substance abuse treatment services.

015

Medical or other remedial care or services, other than physicians' services, provided by licensed practitioners within the scope of practice as defined under State law

016

Home health services - Nursing services

017

Home health services - Home health aide services

018

Home health services - Medical supplies, equipment, and appliances suitable for use in the home

019

Home health services - Physical therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services

020

Home health services - Occupational therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services

021

Home health services - Speech pathology and audiology services provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services

022

Private duty nursing services

023

Advanced practice nurse services

024

Pediatric nurse

025

Nurse-midwife service

026

Nurse practitioner services

027

Respiratory care for ventilator-dependent individuals

028

Clinic services

029

Dental services

030

Physical therapy services (when not provided under home health services)

031

Occupational therapy services (when not provided under home health services)

032

Speech, hearing, and language disorders services (when not provided under home health services)

033

Prescribed drugs

034

Over-the-counter medications.

035

Dentures

036

Prosthetic devices

037

Eyeglasses

038

Hearing Aids

039

Diagnostic services

040

Screening services

041

Preventive services

042

Well-baby and well-child care services as defined by the State.

043

Rehabilitative services

044

Inpatient hospital services for individuals age 65 or older in institutions for mental diseases

045

Nursing facility services for individuals age 65 or older in institutions for mental diseases

046

Intermediate care facility (ICF/IIDICF/IID) services

047

Nursing facility services, other than in institutions for mental diseases

048

Inpatient psychiatric services for individuals under age 21

049

Outpatient mental health services, other than Outpatient substance abuse treatment services. This TOS includes services furnished in a State-operated mental hospital and including community-based services.

050

Inpatient substance abuse treatment services and residential substance abuse treatment services.

051

Personal care services

052

Primary care case management services

053

Targeted case management services

054

Case Management services other than those that meet the definition of primary care case management services or targeted case management services

055

Care coordination services.

056

Transportation services

057

Enabling services

058

Services furnished in a religious nonmedical health care institution

059

Skilled nursing facility services for individuals under age 21

060

Emergency hospital services

061

Critical access hospital services

062

HCBS - Case management services

063

HCBS - Homemaker services

064

HCBS - Home health aide services

065

HCBS - Personal care services

066

HCBS - Adult day health services

067

HCBS - Habilitation services

068

HCBS - Respite care services

069

HCBS - Day treatment or other partial hospitalization services, psychosocial rehabilitation services and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness

070

HCBS - Day Care

071

HCBS - Training for family members

072

HCBS - Minor modification to the home

073

HCBS - Other services requested by the agency and approved by CMS as cost effective and necessary to avoid institutionalization

074

HCBS - Expanded habilitation services - Prevocational services

075

HCBS - Expanded habilitation services - Educational services

076

HCBS - Expanded habilitation services - Supported employment services, which facilitate paid employment

077

HCBS-65-plus - Case management services

078

HCBS-65-plus - Homemaker services

079

HCBS-65-plus - Home health aide services

080

HCBS-65-plus - Personal care services

081

HCBS-65-plus - Adult day health services

082

HCBS-65-plus - Respite care services

083

HCBS-65-plus - Other medical and social services

084

Sterilizations

085

Prenatal care and pre-pregnancy family planning services and supplies.

086

Other Pregnancy-related Procedures

087

Hospice services

088

Any other health care services or items specified by the Secretary and not excluded under regulations.

115

Residential care



Shape43

Provider File Valid Values

PROV-ENROLLMENT-METHOD

Code

Description

1

Enrolled through use of Medicare enrollment system (State did not require that provider submit application. Rather Provider is active Medicare provider and state Medicaid program accepted these credentials as sufficient to participate as state Medicaid provider.)

2

Enrolled through use of state-based provider application

3

Other 





Shape44

Provider File Valid Values

PROV-IDENTIFIER-TYPE

Code

Description

1

State-specific Medicaid Provider ID

2

NPI

3

Medicare ID

4

NCPDP ID

5

Federal Tax ID

6

State Tax ID

7

SSN

8

Other



Shape45

Provider File Valid Values

PROV-MEDICAID-ENROLLMENT-STATUS-CODE

Code

Description

01

Active - Active Do Not Pay              

02

Active - Active Reinstated              

03

Active - Active                         

04

Active - Eligibility Verification

05

Active - Encounter Only        

06

Active - Financial Trans Only    

20

Denied - Denied Two Provider Numbers        

21

Denied - For Other Reasons       

22

Denied - Invalid License         

23

Denied - Not Eligible            

24

Denied - Same Number Assigned       

40

Pending - Enrollment             

41

Pending - License/Cert Verification        

42

Pending - Missing Documentation  

43

Pending - No License/Temp License       

44

Pending - NPI Invalid            

45

Pending - Rate Determination     

46

Pending - Signed Agreement       

47

Pending - Status Approval        

48

Pending - W9 Missing or Incomplete

60

Term - Abuse of billing privileges

61

Term - Action Taken by Medicaid/CHIP

62

Term - Action Taken by Medicare

63

Term - Change of Ownership       

64

Term - Failure to report a change of address/ownership

65

Term - False or misleading information

66

Term - Federal exclusion/ debarment, etc.

67

Term - Felony conviction

68

Term - Involuntary Termination   

69

Term - License Expired           

70

Term - License Revoked           

71

Term - Loss of license or other State action

72

Term - Medicare/Medicaid Exclusion     

73

Term - Medicaid Authority        

74

Term - Medicare Termination      

75

Term - Misuse of billing number

76

Term - No Claims Activity       

77

Term - Non-Compliance

78

Term - Onsite review/ Provider is no longer operational

79

Term - Other

80

Term - Provider Deceased         

81

Term - State exclusion/ debarment, etc.

82

Term - Unknown

83

Term - Voluntary Termination     

Shape46

Provider File Valid Values





Shape47

Provider File Valid Values

PROV-PROFIT-STATUS

01

501(C)(3) NON-PROFIT

02

FOR-PROFIT, CLOSELY HELD

03

FOR-PROFIT, PUBLICLY TRADED

04

OTHER

88

N/A – The individual only practices as part of a group

99

Unknown





Shape48

Provider File Valid Values

RECORD-ID

PRV00001

FILE-HEADER-RECORD-PROVIDER

PRV00002

PROV-ATTRIBUTES-MAIN

PRV00003

PROV-LOCATION-AND-CONTACT-INFO

PRV00004

PROV-LICENSING-INFO

PRV00005

PROV-IDENTIFIERS

PRV00006

PROV-TAXONOMY-CLASSIFICATION

PRV00007

PROV-MEDICAID-ENROLLMENT

PRV00008

PROV-AFFILIATED-GROUPS

PRV00009

PROV-AFFILIATED-PROGRAMS

PRV00010

PROV-BED-TYPE-INFO





Shape49

Provider File Valid Values

SEX

F

Female

M

Male

U

Unknown





Shape50

Provider File Valid Values

STATE-PLAN-ENROLLMENT

1

Medicaid

2

CHIP

3

Both Medicaid and CHIP

4

Not state plan affiliated





Shape51

Provider File Valid Values

SUBMISSION-TRANSACTION-TYPE

C

Create File—a file that contains a complete set of transactions/changes processed since the last Create file submission. States may submit only one valid Create file per reporting period and data file type.

R

Replacement File—a Replacement submission is a replacement of the month’s data. It will completely replace the immediate prior submission. If a later replacement entry is received, it will overwrite the previous replacement, as well as a prior Create or Update submission for the same data type and reporting period.

U

Update File—a file that contains T-MSIS record segments created in response to business rule rejects. Note: The records in an Update file are not generated as a result of a change processed in the state’s Medicaid or Medicaid-related systems during the current reporting month. These Update file record segments may be unchanged from the ones submitted previously for various reasons (for example, the state may be unable to process a change record in their Medicaid / Medicaid-related systems to correct the issue because the state is simply passing through to T-MSIS data that originated outside of the state’s systems).[1] Conversely, the records may be different from those previously submitted, but the change is the result of a fix whose root cause problem was an issue in the T-MSIS file-creation or replacement process at CMS. Regardless, the record was not generated from a change that occurred in the state’s source data.





Shape52

Provider File Valid Values

SUBMITTING-STATE


http://www.census.gov/geo/reference/ansi_statetables.html





Shape53

Provider File Valid Values

TEACHING-IND

0

No

1

Yes



Eligible File Valid Values



Shape54

Eligible File Valid Values

1115A-DEMONSTRATION-IND

0

Not an 1115(A) participant

1

1115(A) participant



Shape55

Eligible File Valid Values

ADDR-TYPE

01

Primary home address and contact information, used for the eligibility determination process

02

Primary work address and contact information

03

Secondary residence and contact information

04

Secondary work address and contact information

05

Other category of address and contact information

06

Eligible person’s official mailing address



Shape56

Eligible File Valid Values

CERTIFIED-AMERICAN-INDIAN/ALASKAN-NATIVE-INDICATOR

0

Not applicable

1

No, Individual does not have CDIB

2

Yes, Individual does have CDIB

9

Applicable but unknown



Shape57

Eligible File Valid Values

CHIP-CODE

0

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

1

Individual was Medicaid eligible, but was not included in either Medicaid-Expansion CHIP or a separate title XXI CHIP) program for the month

2

Individual was included in the Medicaid-Expansion CHIP program and subject to enhanced Federal matching for the month

3

Individual was not Medicaid-Expansion CHIP eligible, but was included in a separate title XXI CHIP program for the month.

4

Individual was both Medicaid-Eligible and Separate CHIP eligible during the same month

9

CHIP status unknown



Shape58

Eligible File Valid Values

CITIZENSHIP-IND

0

No

1

Yes

9

Unknown



Shape59

Eligible File Valid Values

CITIZENSHIP-VERIFICATION-FLAG

0

No

1

Yes

9

Unknown



Shape60

Eligible File Valid Values

CONCEPTION-TO-BIRTH-IND

0

No

1

Yes

9

Unknown



Shape61

Eligible File Valid Values

DISABILITY-TYPE-CODE

01

Individual is deaf or has serious difficulty hearing.

02

Individual is blind or has serious difficulty seeing, even when wearing glasses.

03

Individual has serious difficulty concentrating, remembering, or making decisions because of a physical, mental, or emotional condition. (Applicable only to people who are 5 years old or older.)



04

Individual has serious difficulty walking or climbing stairs. (Applicable only to people who are 5 years old or older.)

05

Individual has difficulty dressing or bathing. (Applicable only to people who are 5 years old or older.)

06

Individual has difficulty doing errands alone such as visiting a doctor's office or shopping because of a physical, mental, or emotional condition. (Applicable only to people who are 15 years old or older.)

07

Other

08

None

99

Unknown



Shape62

Eligible File Valid Values

DUAL-ELIGIBLE-CODE

00

Eligible is not a Medicare beneficiary

01

Eligible is entitled to Medicare- QMB only

02

Eligible is entitled to Medicare- QMB AND Medicaid coverage

03

Eligible is entitled to Medicare- SLMB only

04

Eligible is entitled to Medicare- SLMB AND Medicaid coverage

05

Eligible is entitled to Medicare- QDWI

06

Eligible is entitled to Medicare- Qualifying individuals

08

Eligible is entitled to Medicare- Other Dual Eligibles (Non QMB, SLMB, QDWI or QI)

09

Eligible is entitled to Medicare – Other (This code is to be used only with specific CMS approval.)

10

Separate CHIP Eligible is entitled to Medicare

99

Eligible's Medicare status is unknown.



Shape63

Eligible File Valid Values

ELIGIBILITY-CHANGE-REASON

01

Excess income

02

Excess assets

03

Income reduced

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 (ESI)

11

Gained access to public employees health plan

12

Obtained other coverage (not ESI or public 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

Residence in an Institution for Mental Disease (IMD)

21

Suspension/Termination with reason unknown

22

Other



Shape64

Eligible File Valid Values

ELIGIBILITY-GROUP

See Appendix F: Eligibility Group Table for listing of valid values.



Shape65

Eligible File Valid Values

ELIGIBLE-COUNTY-CODE

http://www.census.gov/geo/reference/codes/cou.html




Shape66

Eligible File Valid Values

ELIGIBLE-STATE


http://www.census.gov/geo/reference/ansi_statetables.html





Shape67

Eligible File Valid Values

ENROLLMENT-TYPE

1

Medicaid

2

CHIP

9

Unknown



Shape68

Eligible File Valid Values

ETHNICITY-CODE

Code

Description

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

5

Hispanic or Latino Unknown

6

Ethnicity Unspecified

9

Ethnicity Unknown



Shape69

Eligible File Valid Values

FILE-ENCODING-SPECIFICATION

Code

Description

FIX

The file follows a fixed length format.

PSV

The file follows a pipe-delimited format



Shape70

Eligible File Valid Values

FILE-NAME

Code

Description

ELIGIBLE

Eligible File



Shape71

Eligible File Valid Values

FILE-STATUS-INDICATOR

Code

Description

P

Production file

T

Test file



Shape72

Eligible File Valid Values

HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE

Code

Description

001

Aged

002

Physical Disabilities

003

Intellectual Disabilities

004

Autism Spectrum Disorder

005

Developmental Disabilities

006

Mental Illness and/or Serious Emotional Disturbance

007

Brain Injury

008

HIV/AIDs

009

Technology Dependent or Medically Fragile

010

Disabled (other)



Shape73

Eligible File Valid Values

HEALTH-HOME-CHRONIC-CONDITION

Code

Description

A

Mental health

B

Substance abuse

C

Asthma

D

Diabetes

E

Heart disease

F

Overweight (BMI of >25)

G

HIV/AIDS

H

Other



Shape74

Eligible File Valid Values

HOUSEHOLD-SIZE

Code

Description

01

1 person

02

2 people

03

3 people

04

4 people

05

5 people

06

6 people

07

7 people

08

8 or more people

99

Unknown number of people



Shape75

Eligible File Valid Values

IMMIGRATION-STATUS

1

Qualified non-citizen

2

Lawfully present under CHIPRA 214

3

Eligible only for payment for emergency services

8

Not Applicable (U.S. citizen)

9

Unknown



Shape76

Eligible File Valid Values

IMMIGRATION-VERIFICATION-FLAG

0

No

1

Yes

9

Unknown



Shape77

Eligible File Valid Values

INCOME-CODE

01

Individual’s State-defined family income is from 0 to 100% of the FPL

02

Individual’s State-defined family income is from 101 to 133% of the FPL

03

Individual’s State-defined family income is from 134 to 150% of the FPL

04

Individual’s State-defined family income is from 151 to 200% of the FPL

05

Individual’s State-defined family income is from 201 to 255% of the FPL

06

Individual’s State-defined family income is from 256 to 300% of the FPL

07

Individual’s State-defined family income is from 301 to 400% of the FPL

08

Individual’s State-defined family income is over 400% of the FPL

88

Not Applicable

99

Unknown



Shape78

Eligible File Valid Values

LEVEL-OF-CARE-STATUS

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

888

Not Applicable (Not in LTSS program)

999

Unknown



Shape79

Eligible File Valid Values

LOCKIN-PROV-TYPE

For a list of provider type codes, see the PROV-CLASSIFICATION-CODE in PROVIDER-FILE where PROV-CLASSIFICATION-TYPE = 3 (Provider Type Code).



Shape80

Eligible File Valid Values

LTSS-LEVEL-CARE

1

Skilled Care

2

Intermediate Care

3

Custodial Care

9

Unknown



Shape81

Eligible File Valid Values

MAINTENANCE-ASSISTANCE-STATUS

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





Shape82

Eligible File Valid Values

MANAGED-CARE-PLAN-TYPE

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)

18

Pharmacy PAHP

60

Accountable Care Organization

70

Health/Medical Home

80

Integrated Care For Dual Eligibles

99

Individual’s managed care plan status is unknown



Shape83

Eligible File Valid Values

MARITAL-STATUS

01

Legally Married (to opposite sex), spouse present

02

Legally Married (to opposite sex), spouse absent

03

Legally Married (to same sex), spouse present

04

Legally Married (to same sex), spouse absent

05

Partnered or in Civil Union (to opposite sex), spouse present

06

Partnered or in Civil Union (to opposite sex), spouse absent

07

Partnered or in Civil Union (to same sex), spouse present

08

Partnered or in Civil Union (to same sex), spouse absent

09

Legally separated (and not married or partnered)

10

Divorced (and not currently married or partnered)

11

Separated (and not currently married or partnered)

12

Widower/Widow (and not currently married or partnered)

13

Never married/partnered

14

Other

99

Unknown



Shape84

Eligible File Valid Values

MEDICAID-BASIS-OF-ELIGIBILITY

00

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

01

Aged Individual

02

Blind/Disabled Individual

03

Not used

04

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

05

Adult (not based on unemployed status)

06

Child of Unemployed Adult (optional)

07

Unemployed Adult (optional)

08

Foster Care Child

10

Refugee Medical Assistance (45 CFR Sub-part G)

11

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

99

Eligibility status unknown



Shape85

Eligible File Valid Values

MFP-LIVES-WITH-FAMILY

0

No

1

Yes

2

Non Participation

9

Unknown





Shape86

Eligible File Valid Values

MFP-QUALIFIED-INSTITUTION

00

Default- Non Participation

01

Nursing Facility

02

ICF/IID (Intermediate Care Facilities for individuals with Intellectual Disabilities)

03

IMD (Institution for Mental Diseases)

04

Hospital

05

Other

99

Unknown



Shape87

Eligible File Valid Values

MFP-QUALIFIED-RESIDENCE

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





Shape88

Eligible File Valid Values

MFP-REASON-PARTICIPATION-ENDED

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



Shape89

Eligible File Valid Values

MFP-REINSTITUTIONALIZED-REASON

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



Shape90

Eligible File Valid Values

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

1

Controlling Health Plan (CHP) ID – the national health plan identifier of a health plan that either controls its own business activities, actions, or policies, or is controlled by an entity that is not a health plan and exercises sufficient control over the subhealth plan(s) under it so as to direct its own business activities, actions, or policies, as well as those of any subhealth plans under it.

2

Subhealth Plan (SHP) ID – the national health plan identifier of a health plan whose business activities, actions, or policies are directed by a controlling health plan. All subhealth HPIDs should be reported.

3

Other Entity Identifier (OEID) – a national identifier for entities that are not health plans, health care providers, or individuals (as defined in 45 CFR 160.103), but that need to be identified in standard transactions (including, for example, third party administrators, transaction vendors, clearinghouses, and other payers). Other entities are not required to obtain an OEID, but they could obtain and use one if they need to be identified in covered transactions.



Shape91

Eligible File Valid Values

PREGNANCY-IND

0

No

1

Yes

9

Unknown



Shape92

Eligible File Valid Values

PRIMARY-LANGUAGE-CODE

See language codes in Appendix G: ISO 639 Language Codes Reference for a list of all valid language codes



Shape93

Eligible File Valid Values

PRIMARY-LANGUAGE-ENGL-PROF-CODE

0

Very Well

1

Well

2

Not well

3

No spoken proficiency

9

Unknown



Shape94

Eligible File Valid Values

RACE

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

Asian Unknown

012

Native Hawaiian

013

Guamanian or Chamorro

014

Samoan

015

Other Pacific Islander

016

Native Hawaiian or Other Pacific Islander Unknown

017

Unspecified

999

Unknown



Shape95

Eligible File Valid Values

RECORD-ID

ELG00001

FILE-HEADER-RECORD-ELIGIBILITY

ELG00002

PRIMARY-DEMOGRAPHICS-ELIGIBILITY

ELG00003

VARIABLE-DEMOGRAPHICS-ELIGIBILITY

ELG00004

ELIGIBILE-CONTACT-INFORMATION

ELG00005

ELIGIBILITY-DETERMINANTS

ELG00006

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION

ELG00007

HEALTH-HOME-SPA-PROVIDERS

ELG00008

HEALTH-HOME-CHRONIC-CONDITIONS

ELG00009

LOCK-IN-INFORMATION

ELG00010

MFP-INFORMATION

ELG00011

STATE-PLAN-OPTION-PARTICIPATION

ELG00012

WAIVER-PARTICIPATION

ELG00013

LTSS-PARTICIPATION

ELG00014

LTSS-PARTICIPATION

ELG00015

ETHNICITY-INFORMATION

ELG00016

RACE-INFORMATION

ELG00017

DISABILITY-INFORMATION

ELG00018

1115A-DEMONSTRATION-INFORMATION

ELG00020

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME

ELG00021

ENROLLMENT-TIME-SPAN



Shape96

Eligible File Valid Values

RESTRICTED-BENEFITS-CODE

0

Individual is not eligible for Medicaid or CHIP during the month.

1

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

2

Individual is eligible for Medicaid or Medicaid-Expansion CHIP, 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 or CHIP but only entitled to restricted benefits for pregnancy-related services.

5

Individual is eligible for Medicaid or Medicaid-Expansion CHIP 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 or Medicaid-Expansion CHIP but only entitled to restricted benefits for family planning services.

7

Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005.

D

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-separate CHIP dental coverage (supplemental dental wraparound benefit to employer-sponsored insurance)



Shape97

Eligible File Valid Values

SEX

F

Female

M

Male

U

Unknown



Shape98

Eligible File Valid Values

SSDI-IND

0

No

1

Yes

9

Unknown





Shape99

Eligible File Valid Values

SSI-STATE-SUPPLEMENT-STATUS-CODE

000

Not Applicable

001

Mandatory

002

Optional

999

Unknown

SSI-STATUS

Shape100

Eligible File Valid Values

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



Shape101

Eligible File Valid Values

SSN-INDICATOR

0

State does not use SSN as MSIS-IDENTIFICATION-NUMBER

1

State uses SSN as MSIS-IDENTIFICATION-NUMBER



Shape102

Eligible File Valid Values

SSN-VERIFICATION-FLAG

0

SSN not verified

1

SSN successfully verified by SSA

2

SSN is pending SSA verification

9

Unknown



Shape103

Eligible File Valid Values

STATE-PLAN-OPTION-TYPE

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



Shape104

Eligible File Valid Values

SUBMISSION-TRANSACTION-TYPE

C

Create File—a file that contains a complete set of transactions/changes processed since the last Create file submission. States may submit only one valid Create file per reporting period and data file type.

R

Replacement File—a Replacement submission is a replacement of the month’s data. It will completely replace the immediate prior submission. If a later replacement entry is received, it will overwrite the previous replacement, as well as a prior Create or Update submission for the same data type and reporting period.

U

Update File—a file that contains T-MSIS record segments created in response to business rule rejects. Note: The records in an Update file are not generated as a result of a change processed in the state’s Medicaid or Medicaid-related systems during the current reporting month. These Update file record segments may be unchanged from the ones submitted previously for various reasons (for example, the state may be unable to process a change record in their Medicaid / Medicaid-related systems to correct the issue because the state is simply passing through to T-MSIS data that originated outside of the state’s systems).[1] Conversely, the records may be different from those previously submitted, but the change is the result of a fix whose root cause problem was an issue in the T-MSIS file-creation or replacement process at CMS. Regardless, the record was not generated from a change that occurred in the state’s source data.





Shape105

Eligible File Valid Values

SUBMITTING-STATE


http://www.census.gov/geo/reference/ansi_statetables.html





Shape106

Eligible File Valid Values

TANF-CASH-CODE

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



Shape107

Eligible File Valid Values

VETERAN-IND

0

No

1

Yes

9

Unknown



Shape108

Eligible File Valid Values

WAIVER-TYPE

00

Not Eligible- The individual was not eligible for Medicaid or CHIP

01

1115 Other 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) – Aged and Disabled

07

1915(c) – Aged

08

1915(c) – Physical Disabilities

09

1915(c) – Intellectual Disabilities

10

1915(c) – Intellectual and Developmental Disabilities

11

1915(c) – Brain Injury

12

1915(c) – HIV/AIDS

13

1915(c) – Technology Dependent or Medically Fragile

14

1915(c) –Disabled (other)

15

1915(c) - Enrolled in 1915(c) waiver for unspecified or unknown populations

16

1915(c) - Autism/Autism spectrum disorder

17

1915(c) – Developmental Disabilities

18

1915(c) – Mental Illness - Age 18 or Older

19

1915(c) – Mental Illness - Under Age 18

20

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)

21

1115 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.

22

1115 Pharmacy Plus 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.

23

1115 Disaster-Related Waiver – The associated Waiver-ID is for a disaster-related waiver that allows for coverage related to a hurricane or other disaster.

24

1115 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 or CHIP, but is NOT enrolled in a waiver.

99

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







Third-party Liability File Valid Values



Shape109

Third-party Liability File Valid Values

COVERAGE-TYPE

01

Drug

02

Professional (Physician) Visit - Office

03

Dental Care

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

Rehabilitation

16

Cancer

17

Emergency Services

18

Chiropractic

19

Surgical

20

Diagnostic Medical, including X-ray and Lab Services

21

PT/OT/ST

22

Hospice

23

Transportation

98

Other

99

Unknown



Shape110

Third-party Liability File Valid Values

FILE-ENCODING-SPECIFICATION

FLF

The file follows a fixed length format.

PSV

The file follows a pipe-delimited format.



Shape111

Third-party Liability File Valid Values

FILE-NAME

TPL-FILE

Third Party Liability File



Shape112

Third-party Liability File Valid Values

FILE-STATUS-INDICATOR

P

Production file

T

Test



Shape113

Third-party Liability File Valid Values

INSURANCE-CARRIER-STATE

http://www.census.gov/geo/reference/ansi_statetables.html



Shape114

Third-party Liability File Valid Values

INSURANCE-PLAN-TYPE

01

Medical or comprehensive health insurance plan (e.g. HMO)

02

Dental health insurance plan

03

Vision health insurance plan

04

Prenatal/delivery health insurance plan

05

Long term care health insurance plan (Long Term PIHP)

06

Transportation health insurance plan (Transportation PAHP)

07

A managed care plan

08

Disease management health insurance plan (Disease Management PAHP)

09

PAHP (Medical only)

10

Comprehensive health insurance and Long Term Care (hybrid)

11

Other health insurance plan

12

Veterans Administration health benefits

13

Indian Health Service Program health benefits

14

TRICARE health benefits

15

Eligible enrolled in private LTC insurance

16

Fee-for-Service insurance

99

Health insurance plan type is unknown



Shape115

Third-party Liability File Valid Values

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

1

Controlling Health Plan (CHP) ID – the national health plan identifier of a health plan that either controls its own business activities, actions, or policies, or is controlled by an entity that is not a health plan and exercises sufficient control over the subhealth plan(s) under it so as to direct its own business activities, actions, or policies, as well as those of any subhealth plans under it.

2

Subhealth Plan (SHP) ID – the national health plan identifier of a health plan whose business activities, actions, or policies are directed by a controlling health plan. All subhealth HPIDs should be reported.

3

Other Entity Identifier (OEID) – a national identifier for entities that are not health plans, health care providers, or individuals (as defined in 45 CFR 160.103), but that need to be identified in standard transactions (including, for example, third party administrators, transaction vendors, clearinghouses, and other payers). Other entities are not required to obtain an OEID, but they could obtain and use one if they need to be identified in covered transactions.


Shape116

Third-party Liability File Valid Values

POLICY-OWNER-CODE

01

Self

02

Spouse

03

Custodial Parent

04

Noncustodial Parent (Child Support Enforcement in effect)

05

Noncustodial Parent without child support enforcement in effect

06

Grandparent

07

Guardian

08

Domestic Partner

09

Other

99

Unknown



Shape117

Third-party Liability File Valid Values

RECORD-ID

TPL00001

FILE-HEADER-RECORD-TPL

TPL00002

TPL-MEDICAID-ELIGIBLE-PERSON-MAIN

TPL00003

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO

TPL00004

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES

TPL00005

TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION

TPL00006

TPL-ENTITY-CONTACT-INFORMATION



Shape118

Third-party Liability File Valid Values

SSN-INDICATOR

0

State does not use SSN as MSIS-IDENTIFICATION-NUMBER

1

State uses SSN as MSIS-IDENTIFICATION-NUMBER



Shape119

Third-party Liability File Valid Values

SUBMISSION-TRANSACTION-TYPE

C

Create File—a file that contains a complete set of transactions/changes processed since the last Create file submission. States may submit only one valid Create file per reporting period and data file type.

R

Replacement File—a Replacement submission is a replacement of the month’s data. It will completely replace the immediate prior submission. If a later replacement entry is received, it will overwrite the previous replacement, as well as a prior Create or Update submission for the same data type and reporting period.

U

Update File—a file that contains T-MSIS record segments created in response to business rule rejects. Note: The records in an Update file are not generated as a result of a change processed in the state’s Medicaid or Medicaid-related systems during the current reporting month. These Update file record segments may be unchanged from the ones submitted previously for various reasons (for example, the state may be unable to process a change record in their Medicaid / Medicaid-related systems to correct the issue because the state is simply passing through to T-MSIS data that originated outside of the state’s systems).[1] Conversely, the records may be different from those previously submitted, but the change is the result of a fix whose root cause problem was an issue in the T-MSIS file-creation or replacement process at CMS. Regardless, the record was not generated from a change that occurred in the state’s source data.



Shape120

Third-party Liability File Valid Values

SUBMITTING-STATE


http://www.census.gov/geo/reference/ansi_statetables.html



Shape121

Third-party Liability File Valid Values

TPL-ENTITY-ADDR-TYPE

06

TPL-Entity Corporate Location

07

TPL-Entity Mailing

08

TPL-Entity Satellite Location

09

TPL-Entity Billing

10

TPL-Entity Correspondence

11

TPL-Other



Shape122

Third-party Liability File Valid Values

TPL-HEALTH-INSURANCE-COVERAGE-IND

0

Eligible individual has no TPL insurance coverage.

1

Eligible individual does have TPL insurance coverage.



Shape123

Third-party Liability File Valid Values

TPL-OTHER-COVERAGE-IND

0

Eligible individual has no other TPL funding available.

1

Eligible individual does have other TPL funding available.



Shape124

Third-party Liability File Valid Values

TYPE-OF-OTHER-THIRD-PARTY-LIABILITY

1

Tort/Casualty Claim

2

Medical Malpractice

3

Estate (an estate, annuity or designated trust)

4

Liens

5

Worker’s Compensation

6

Payments from an individual or group who has either voluntarily or been assigned legal responsibility for the health care of one or more Medicaid recipients; fraternal groups; unions

7

Other – unidentified

9

Unknown



Claims Files Valid Values

All valid values for CLAIM-IP, CLAIM-LT, CLAIM-OT, and CLAIM-RX files are included



Shape125

Claims Files Valid Values

1115A-DEMONSTRATION-IND

0

No

1

Yes



Shape126

Claims Files Valid Values

ADJUSTMENT-IND

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



Shape127

Claims Files Valid Values

ADJUSTMENT-REASON-CODE

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/



Shape128

Claims Files Valid Values

ADMISSION-HOUR

00

0:00-0:59

01

1:00-1:59

02

2:00-2:59

03

3:00-3:59

04

4:00-4:59

05

5:00-5:59

06

6:00-6:59

07

7:00-7:59

08

8:00-8:59

09

9:00-9:59

10

10:00-10:59

11

11:00-11:59

12

12:00-12:59

13

13:00-13:59

14

14:00-14:59

15

15:00-15:59

16

16:00-16:59

17

17:00-17:59

18

18:00-18:59

19

19:00-19:59

20

20:00-20:59

21

21:00-21:59

22

22:00-22:59

23

23:00-23:59



Shape129

Claims Files Valid Values

ADMISSION-TYPE

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

The patient is a newborn delivered either inside the admitting hospital (UB04 FL 15 value “5” [A baby born inside the admitting hospital] or outside of the hospital (UB04 FL 15 value “6” [A baby born outside the admitting hospital]).

5

TRAUMA

The patient visits a trauma center( A trauma center means a facility licensed or designated by the State or local government authority authorized to do so, or as verified by the American College of surgeons and involving a trauma activation.)

8

NOT AVALIABLE


9

UNKNOWN


Shape130

Claims Files Valid Values

ADMITTING-DIAGNOSIS-CODE

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html



Shape131

Claims Files Valid Values

ADMITTING-DIAGNOSIS-CODE-FLAG

1

ICD-9

2

ICD-10

3

Other

9

Unknown





Shape132

Claims Files Valid Values

ADMITTING-PROV-NPI-NUM

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf





ADMITTING-PROV-SPECIALTY

See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values.





Shape133

Claims Files Valid Values



Shape134

Claims Files Valid Values

ADMITTING-PROV-TAXONOMY

http://www.wpc-edi.com/reference/





Shape135

Claims Files Valid Values

ADMITTING-PROV-TYPE

See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values.



ALLOWED-CHARGE-SRC

Shape136

Claims Files Valid Values

1

Priced using QMB Pricing

2

Lab panel bundled

4

Priced using RBRVS

5

Anesthesia pricing

7

APC priced



A

Manually priced

B

By report

C

Maximum fee

D

Percent of charges

E

Reimbursement Rate

F

Lower level screening fee

G

Billed Charges

H

Denied

I

Medicare Coins and deductible

K

Medicare allowed amount

M

Medicare prevailing

P

DRG

R

DRG w/cost outlier

U

DRG priced by proration

V

Mid-level priced

Z

ATP Bundled

9

Unknown





BENEFIT-TYPE

Code Value

Shape137

Claims Files Valid Vales

Code Definition

 

Mandatory Benefits for Categorically Needy (Mandatory and Options for Coverage) Individuals and Optional Benefits for Medically Needy Individuals

001

Inpatient Hospital Services

002

Outpatient Hospital Services

003

Rural health clinic services

004

FQHC services

005

Other Laboratory and X-Ray Services

006

Nursing Facility Services for 21 and over

007

EPSDT

008

Family Planning Services

009

Mandatory tobacco cessation counseling for pregnant women under 1905(a)(4)(D)

010

Physicians' Services

011

Medical and Surgical Services Furnished by a Dentist

012

Nurse-midwife services

013

Certified pediatric or family nurse practitioners' services

014

Free Standing Birth Center Services

015

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

016

Home Health Services - Home Health Aide Services Provided by a Home Health Agency

017

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

 

Optional Benefits for Categorically Needy (Mandatory and Options for Coverage) and Medically Needy Individuals

018

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

019

Shape138

Claims Files Valid Values

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

020

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

021

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

022

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

023

Private Duty Nursing

024

Clinic Services

025

Dental Services

026

Physical Therapy and Related Services - Physical Therapy

027

Physical Therapy and Related Services - Occupational Therapy

028

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

029

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

030

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

031

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

032

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

033

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

034

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

035

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

036

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

037

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

038

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

039

Intermediate Care Facility Services for individuals with intellectual disabilities or persons with related conditions

040

Inpatient psychiatric facility services for under 21

041

Hospice Care

042

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)

043

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

044

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

045

Personal care services

046

Primary care case management services

047

Special sickle-cell anemia-related services

048

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

049

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

050

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

051

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

052

Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Critical Access Hospitals

053

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

054

Community First Choice

055

Health Home Services

 

Special Benefit Provisions

056

Limited Pregnancy-Related Services for Pregnant Women with Income Above the Applicable Income Limit

057

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

058

Benefits for Families Receiving Transitional Medical Assistance

059

Standards for Coverage of Transplant Services

060

School-Based Services Payment Methodologies

061

Indian Health Services and Tribal Health Facilities

062

Methods and Standards to Assure High Quality Care

 

Coordination of Medicaid with Medicare and Other Insurance

063

Medicare Premium Payments

064

Medicare Coinsurance and Deductibles

065

Other Medical Insurance Premium Payments

 

Special Benefit Programs

066

Programs for Distribution of Pediatric Vaccines

 

Home and Community-Based Services

067

Laboratory and x-ray services

068

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

069

Private duty nursing services

070

Physical Therapy and Related Services - Audiology services

071

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.

072

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

073

Emergency services for certain legalized aliens and undocumented aliens

074

Licensed or Otherwise State-Approved Free-Standing Birthing Center and other ambulatory services that are offered by a freestanding birth center

075

Homemaker

076

Home Health Aide

077

Adult Day Health services

078

Shape139

Claims Files Valid Values

Habilitation

079

Habilitation: Residential Habilitation

080

Habilitation: Supported Employment

081

Habilitation: Education (non IDEA available)

082

Habilitation: Day Habilitation

083

Habilitation: Pre-Vocational

084

Habilitation: Other Habilitative Services

085

Respite

086

Day Treatment (mental health service)

087

Psychosocial rehabilitation

088

Environmental Modifications (Home Accessibility Adaptations)

089

Vehicle Modifications

090

Non-Medical Transportation

091

Special Medical Equipment (minor assistive Devices)

092

Home Delivered meals

093

Assistive Technology (i.e., communication devices)

094

Personal Emergency Response (PERS)

095

Nursing Services

096

Community Transition Services

097

Adult Foster Care

098

Day Supports (non-habilitative)

099

Supported Employment

100

Supported Living Arrangements

101

Supports for Consumer Direction (Supports Facilitation)

102

Participant Directed Goods and Services

103

Senior Companion (Adult Companion Services)

104

Assisted Living

 

Other

105

Program for All-inclusive Care for the Elderly (PACE) Services

106

Self-directed Personal Assistance Services under 1915(j)



Shape140

Claims Files Valid Values

BILLING-PROV-NPI-NUM

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf



Shape141

Claims Files Valid Values

BILLING-PROV-SPECIALTY

  • See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values.

Shape142

Claims Files Valid Values

BILLING-PROV-TAXONOMY

http://www.wpc-edi.com/reference/



Shape143

Claims Files Valid Values

BILLING-PROV-TYPE

  • See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values.

Shape144

Claims Files Valid Values

BILLING-UNIT

01

Per Day

02

Per Hour

03

Per Case

04

Per Encounter

05

Per Week

06

Per Month

07

Other Arrangements

99

Unknown



Shape145

Claims Files Valid Values

BORDER-STATE-IND

0

No

1

Yes





Shape146

Claims Files Valid Values

BRAND-GENERIC-IND

0

Non-Drug

1

Generic

2

Brand

3

Multi-Source

4

Single-Source



Shape147

Claims Files Valid Values

CLAIM-DENIED-INDICATOR

0

Denied: The payment of claim in its entirety was denied by the state.

1

Not Denied: The state paid some or all of the claim.



Shape148

Claims Files Valid Values

CLAIM-LINE-STATUS

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/




Shape149

Claims Files Valid Values

CLAIM-PYMT-REM-CODE-1 to CLAIM-PYMT-REM-CODE-4

http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes)



Shape150

Claims Files Valid Values

CLAIM-STATUS

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/



Shape151

Claims Files Valid Values

CLAIM-STATUS-CATEGORY

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/



Shape152

Claims Files Valid Values

CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT

01

Federal funding under Title XIX

02

Federal funding under Title XXI

03

Federal funding under ACA

04

Federal funding under other legislation



Shape153

Claims Files Valid Values

COMPOUND-DOSAGE-FORM

01

Capsule

02

Ointment

03

Cream

04

Suppository

05

Powder

06

Emulsion

07

Liquid

10

Tablet

11

Solution

12

Suspension

13

Lotion

14

Shampoo

15

Elixir

16

Syrup

17

Lozenge

18

Enema



Shape154

Claims Files Valid Values

COMPOUND-DRUG-IND

0

Not Compound

1

Compound

9

Unknown



Shape155

Claims Files Valid Values

COPAY-WAIVED-IND

0

Not Waived: The provider did not waive the beneficiary’s copayment,

1

Waived: The provider waived the beneficiary’s copayment.

8

Not Applicable: The benefit plan does not have a copay in this circumstance



Shape156

Claims Files Valid Values

CROSSOVER-INDICATOR

0

Not Crossover Claim

1

Crossover Claim

9

Unknown



Shape157

Claims Files Valid Values

DESTINATION-STATE


http://www.census.gov/geo/reference/ansi_statetables.html



Shape158

Claims Files Valid Values

DIAGNOSIS-CODE-1 to DIAGNOSIS-CODE-12

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html







Shape159

Claims Files Valid Values

DIAGNOSIS-CODE-FLAG-1 to DIAGNOSIS-CODE-FLAG-12

1

ICD-9

2

ICD-10

3

Other

9

Unknown



Shape160

Claims Files Valid Values



DIAGNOSIS-POA-FLAG-1 to DIAGNOSIS-POA-FLAG-12

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.

BLANK

Exempt from POA reporting.





Shape161

Claims Files Valid Values

DISCHARGE-HOUR

00

0:00-0:59

01

1:00-1:59

02

2:00-2:59

03

3:00-3:59

04

4:00-4:59

05

5:00-5:59

06

6:00-6:59

07

7:00-7:59

08

8:00-8:59

09

9:00-9:59

10

10:00-10:59

11

11:00-11:59

12

12:00-12:59

13

13:00-13:59

14

14:00-14:59

15

15:00-15:59

16

16:00-16:59

17

17:00-17:59

18

18:00-18:59

19

19:00-19:59

20

20:00-20:59

21

21:00-21:59

22

22:00-22:59

23

23:00-23:59



Shape162

Claims Files Valid Values

DISPENSING-PRESCRIPTION-DRUG-PROV-NPI

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf



Shape163

Claims Files Valid Values



DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY

http://www.wpc-edi.com/reference/



Shape164

Claims Files Valid Values

DRG-DESCRIPTION

http://www.cms.hhs.gov/MedicareFeeforSvcPartsAB/Downloads/DRGdesc06.pdf

http://edocket.access.gpo.gov/2009/pdf/E9-12907.pdf



Shape165

Claims Files Valid Values

DRUG-UTILIZATION-CODE

439-E4 (Reason for Service Code) for the Conflict Codes

AD

Additional Drug Needed

AN

Prescription Authentication

AR

Adverse Drug Reaction

AT

Additive Toxicity

CD

Chronic Disease Management

CH

Call Help Desk

CS

Patient Complaint/Symptom

DA

Drug-Allergy

DC

Drug-Disease (Inferred)

DD

Drug-Drug Interaction

DF

Drug-Food interaction

DI

Drug Incompatibility

DL

Drug-Lab Conflict

DM

Apparent Drug Misuse

DS

Tobacco Use

ED

Patient Education/Instruction

ER

Overuse

EX

Excessive Quantity

HD

High Dose

IC

Iatrogenic Condition

ID

Ingredient Duplication

LD

Low Dose

LK

Lock In Recipient

LR

Underuse

MC

Drug-Disease (Reported)

MN

Insufficient Duration

MS

Missing Information/Clarification

MX

Excessive Duration

NA

Drug Not Available

NC

Non-covered Drug Purchase

ND

New Disease/Diagnosis

NF

Non-Formulary Drug

NN

Unnecessary Drug

NP

New Patient Processing

NR

Lactation/Nursing Interaction

NS

Insufficient Quantity

OH

Alcohol Conflict

PA

Drug-Age

PC

Patient Question/Concern

PG

Drug-Pregnancy

PH

Preventive Health Care

PN

Prescriber Consultation

PP

Plan Protocol

PR

Prior Adverse Reaction

PS

Product Selection Opportunity

RE

Suspected Environmental Risk

RF

Health Provider Referral

44Ø-E5 (Professional Service Code) for the Intervention Codes

ØØ

No intervention

AS

Patient assessment

CC

Coordination of care

DE

Dosing evaluation/determination

FE

Formulary enforcement

GP

Generic product selection

MA

Medication administration

Prescriber consulted

MR

Medication review

PE

Patient education/instruction

PH

Patient medication history

PM

Patient monitoring

Patient consulted

PT

Perform laboratory test

Pharmacist consulted other source

RT

Recommend laboratory test

SC

Self-care consultation

SW

Literature search/review

TC

Payer/processor consulted

TH

Therapeutic product interchange

441-E6 (Result of Service Code) for the Output Codes

ØØ

Not Specified

1A

Filled As Is, 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

1H

Brand-to-Generic Change

1J

Rx-to-OTC Change

1K

Filled with Different Dosage Form

2A

Prescription Not Filled

2B

Not Filled, Directions Clarified

3A

Recommendation Accepted

3B

Recommendation Not Accepted

3C

Discontinued Drug

3D

Regimen Changed

3E

Therapy Changed

3F

Therapy Changed-cost increased acknowledged

3G

Drug Therapy Unchanged

3H

Follow-Up/Report

3J

Patient Referral

3K

Instructions Understood

3M

Compliance Aid Provided

3N

Medication Administered



Shape166

Claims Files Valid Values

FILE-ENCODING-SPECIFICATION

FLF

The file follows a fixed length format.

PSV

The file follows a pipe-delimited format.



Shape167

Claims Files Valid Values

FILE-NAME

CLAIM-IP

Inpatient Claim/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 001, 058, 084, 086, 090, 091, 092, 093, 123, or 132.

(Note : In CLAIMIP, TYPE-OF-SERVICE 086 and 084 refer only to services received on an inpatient basis.)

CLAIM-LT

Long Term Care Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 009, 044, 045, 046, 047, 048, 059, or 133 (all mental hospital, and NF services).
(Note: Individual services billed by a long-term care facility belong in this file regardless of service type.)

CLAIM-OT

Other Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE= 002, 003, 004, 005, 006, 007, 008, 010, 011, 012, 013, 015, 016, 017, 018, 019, 020, 021, 022, 025, 026, 027, 028, 029, 030, 031, 032, 035, 036, 037, 039, 040, 041, 043, 051, 052, 053, 054, 056, 060, 061, 062, 063, 064, 065, 066, 067, 068, 069, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083, 087, 115, 119, 120, 121, 122, 131, or 134.

CLAIM-RX

Pharmacy Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE= 033, 034, or 131.





Shape168

Claims Files Valid Values

FILE-STATUS-INDICATOR

P

Production File

T

Test File



Shape169

Claims Files Valid Values

FIXED-PAYMENT-IND

0

Not Fixed Payment

1

FFS Fixed Payment





Shape170

Claims Files Valid Values

FORCED-CLAIM-IND

0

No

1

Yes



Shape171

Claims Files Valid Values

FUNDING-CODE

A

Medicaid Agency

B

CHIP Agency

C

Mental Health Service Agency

D

Education Agency

E

Child and Family Services Agency

F

County

G

City

H

Providers

I

Other


Shape172

Claims Files Valid Values

FUNDING-SOURCE-NONFEDERAL-SHARE

01

State appropriations to the Medicaid agency

02

Intergovernmental transfers (IGT)

03

Certified public expenditures (CPE)

04

Provider taxes

05

Donations 

06

State appropriations to the CHIP agency

HCBS-SERVICE-CODE

Shape173

Claims Files Valid Values



1

The HCBS service was provided under 1915(i)

2

The HCBS service was provided under 1915(j)

3

The HCBS service was provided under 1915(k)

4

The HCBS service was provided under a 1915(c) HCBS Waiver

5

The HCBS service was provided under an 1115 waiver

6

The HCBS service was not provided under the statutes identified above and was of an acute care nature

7

The HCBS service was not provided under the statutes identified above and was of a long term care nature

8

The service is not an HCBS service (i.e. the HCBS classification is not applicable)

9

Unknown



Shape174

Claims Files Valid Values

HCBS-TAXONOMY

01010

Case Management

02011

Group Living, Residential Habilitation

02012

Group Living, Mental Health Services

02013

Group Living, Other

02021

Shared Living, Residential Habilitation

02022

Shared Living, Mental Health Services

02023

Shared Living, Other

02031

In-e Residential Habilitation

02032

In-Home Round-The-Clock Mental Health Services

02033

In-Home Round-The-Clock Services, Other

03010

Job Development

03021

Ongoing Supported Employment, Individual

03022

Ongoing Supported Employment, Group

03030

Career Planning

04010

Prevocational Services

04020

Day Habilitation

04030

Education Services

04040

Day Treatment/Partial Hospitalization

04050

Adult Day Health

04060

Adult Day Services (Social Model)

04070

Community Integration

04080

Medical Day Care for Children

05010

Private Duty Nursing

05020

Skilled Nursing

06010

Home Delivered Meals

07010

Rent and Food Expenses For Live-In Caregiver

08010

Home-Based Habilitation

08020

Home Health Aide

08030

Personal Care

08040

Companion

08050

Homemaker

08060

Chore

09011

Respite, Out-Of-Home

09012

Respite, In-Home

09020

Caregiver Counseling and/or Training

10010

Mental Health Assessment

10020

Assertive Community Treatment

10030

Crisis Intervention

10040

Behavior Support

10050

Peer Specialist

10060

Counseling

10070

Psychosocial Rehabilitation

10080

Clinic Services

10090

Other Mental Health and Behavioral Services

11010

Health Monitoring

11020

Shape175

Claims Files Valid Values

Health Assessment

11030

Medication Assessment and/or Management

11040

Nutrition Consultation

11050

Physician Services

11060

Prescription Drugs

11070

Dental Services

11080

Occupational Therapy

11090

Physical Therapy

11100

Speech, Hearing, And Language Therapy

11110

Respiratory Therapy

11120

Cognitive Rehabilitative Therapy

11130

Other Therapies

12010

Financial Management Services In Support Of Participant Direction

12020

Information and Assistance In Support Of Participant Direction

13010

Participant Training

14010

Personal Emergency Response System (Pers)

14020

Home and/or Vehicle Accessibility Adaptations

14031

Equipment and Technology

14032

Supplies

15010

Non-Medical Transportation

16010

Community Transition Services

17010

Goods and Services

17020

Interpreter

17030

Housing Consultation

17990

Other





Shape176

Claims Files Valid Values

HCPCS-RATE

http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/medhcpcsgeninfo/



Shape177

Claims Files Valid Values

HEALTH-CARE-ACQUIRED-CONDITION-IND

0

No

1

Yes

9

Unknown





Shape178

Claims Files Valid Values

HEALTH-HOME-ENTITY-NAME



The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|).

Shape179

Claims Files Valid Values

HEALTH-HOME-PROVIDER-NPI

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf



Shape180

Claims Files Valid Values

HEALTH-HOME-PROV-IND

0

No

1

Yes

8

Not Applicable

9

Unknown



Shape181

Claims Files Valid Values

IMMUNIZATION-TYPE

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

29

Other

88

Not Applicable

99

Unknown



Shape182

Claims Files Valid Values

LINE-ADJUSTMENT-IND

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



Shape183

Claims Files Valid Values

LINE-ADJUSTMENT-REASON-CODE

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/



Shape184

Claims Files Valid Values

MEDICARE-COMB-DED-IND

0

Amount not combined with coinsurance amount

1

Amount combined with coinsurance amount

9

Unknown



Shape185

Claims Files Valid Values

MEDICARE-REIM-TYPE

01

IPPS - Acute Inpatient PPS

02

LTCHPPS - Long-term Care Hospital PPS

03

SNFPPS - Skilled Nursing Facility PPS

04

HHPPS - Home Health PPS

05

IRFPPS - Inpatient Rehabilitation Facility PPS

06

IPFPPS - Inpatient Psychiatric Facility PPS

07

OPPS - Outpatient PPS

08

Fee Schedules (for physicians, DME, ambulance, and clinical lab)

09

Part C Hierarchical Condition Category Risk Assessment (CMS-HCC RA)

Capitation Payment Model



Shape186

Claims Files Valid Values

NEW-REFILL-IND

00

New Prescription

01-98

Number of Refill(s)

99

Unknown



Shape187

Claims Files Valid Values

NDC-UNIT-OF-MEASURE

Code

Description

F2

International Unit

ML

Milliliter

ME

Milligram

GR

Gram

UN

Unit



Shape188

Claims Files Valid Values

OCCURRENCE-CODE-01 to OCCURRENCE-CODE-10

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf





Shape189

Claims Files Valid Values

OPERATING-PROV-NPI-NUM

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf



Shape190

Claims Files Valid Values

OPERATING-PROV-TAXONOMY

http://www.wpc-edi.com/reference/





Shape191

Claims Files Valid Values

ORIGINATION-STATE


http://www.census.gov/geo/reference/ansi_statetables.html



Shape192

Claims Files Valid Values

OTHER-INSURANCE-IND

0

No

1

Yes

9

Unknown





Shape193

Claims Files Valid Values

OTHER-TPL-COLLECTION

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







Shape194

Claims Files Valid Values

OUTLIER-CODE

00

No Outlier

01

Day Outlier

02

Cost Outlier

06

Valid DRG Received from the intermediary

07

CMS Developed DRG

08

CMS Developed DRG Using Patient Status Code

09

Not Group able

10

Composite of cost outliers





Shape195

Claims Files Valid Values

PATIENT-STATUS

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0801.pdf



To order the current edition of the UB-04 Data Specifications Manual go to: http://www.nubc.org/subscriber/index.dhtml

American Hospital Association
155 North Wacker Drive, Suite 400
Chicago, IL 60606
Phone: 312-422-3000
Fax: 312-422-4500



Shape196

Claims Files Valid Values

PAYMENT-LEVEL-IND

1

Claim Header – Sum of Line Item payments

2

Claim Detail – Individual Line Item payments



Shape197

Claims Files Valid Values

PLACE-OF-SERVICE

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf





Shape198

Claims Files Valid Values

PRESCRIBING-PROV-SPECIALTY

See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values.







Shape199

Claims Files Valid Values

PRESCRIBING-PROV-TAXONOMY

http://www.wpc-edi.com/reference/



Shape200

Claims Files Valid Values

PRESCRIBING-PROV-TYPE

  • See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values.

Shape201

Claims Files Valid Values

PROCEDURE-CODE 1 TO PROCEDURE-CODE-6

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html

http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/medhcpcsgeninfo/

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

Additional CPT codes are available for a fee through professional organizations.




Shape202

Claims Files Valid Values

PROCEDURE-CODE-FLAG-1 - PROCEDURE-CODE-FLAG-6

01

CPT 4

02

ICD-9 CM

06

HCPCS (Both National and Regional HCPCS)

07

ICD-10 - CM PCS (Will be implemented on 10/1/2014)

10-87

Other Systems

88

Not Applicable

99

Unknown



Shape203

Claims Files Valid Values

PROGRAM-TYPE

Code

Description

00

No Special Program

01

EPSDT

02

Family Planning

03

Rural Health Clinic

04

Federally Qualified Health Centers (FQHC)

05

Indian Health Services

07

Home and Community Based Care Waiver Services

08

Money Follows the Person (MFP)

10

BIP - Balancing Incentive Payment

11

Community First Choice (1915(k))

12

Medicaid Emergency Psychiatric Demonstration

13

Home and Community Based Services (HCBS) State Plan Option (1915(i))

14

State Plan CHIP

15

Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF)

16

1915(j) (Self- directed personal assistance services/personal care under State Plan or 1915(c) waiver)

99

Unknown



































Shape204

Claims Files Valid Values

PROV-FACILITY-TYPE

Source:

http://www.wpc-edi.com/reference/







Provider Facility Type Code

Provider Facility Type Description


100000000

Individuals or Groups (of Individuals)


170000000

Non-Individual - Other Service Providers


250000000

Non-Individual - Agencies


260000000

Non-Individual - Ambulatory Health Care Facilities


270000000

Non-Individual - Hospital Units


280000000

Non-Individual - Hospitals


290000000

Non-Individual - Laboratories


300000000

Non-Individual - Managed Care Organizations


310000000

Non-Individual - Nursing & Custodial Care Facilities


320000000

Non-Individual - Residential Treatment Facilities


330000000

Non-Individual - Suppliers


340000000

Non-Individual - Transportation Services


380000000

Non-Individual - Respite Care Facility




(Note: Appendix L takes the WPC taxonomy codes and relates each one to its provider facility type code)



Shape205

Claims Files Valid Values

REBATE-ELIGIBLE-INDICATOR

0

NDC is not eligible for drug rebate program. (Manufacturer does not have a rebate agreement.)

1

NDC is eligible for drug rebate program

2

NDC is exempt from the drug rebate program (biological and medical devices)

9

The drug rebate eligibility of the is unknown



Shape206

Claims Files Valid Values

RECORD-ID

CIP00001

FILE-HEADER-RECORD-IP

CIP00002

CLAIM-HEADER-RECORD-IP

CIP00003

CLAIM-LINE-RECORD-IP

CLT00001

FILE-HEADER-RECORD-LT

CLT00002

CLAIM-HEADER-RECORD-LT

CLT00003

CLAIM-LINE-RECORD-LT

COT00001

FILE-HEADER-RECORD-OT

COT00002

CLAIM-HEADER-RECORD-OT

COT00003

CLAIM-LINE-RECORD-OT

CRX00001

FILE-HEADER-RECORD-RX

CRX00002

CLAIM-HEADER-RECORD-RX

CRX00003

CLAIM-LINE-RECORD-RX



Shape207

Claims Files Valid Values

REFERRING-PROV-NPI-NUMBER

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf





Shape208

Claims Files Valid Values

REFERRING-PROV-SPECIALTY

  • See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values.

Shape209

Claims Files Valid Values

REFERRING-PROV-TAXONOMY

Shape210

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/TaxonomyCrosswalk.pdf

http://www.wpc-edi.com/reference/

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






Shape211

Claims Files Valid Values

REFERRING-PROV-TYPE

  • See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values.

Shape212

Claims Files Valid Values

SELF-DIRECTION-TYPE

000

Not Applicable

001

Hiring Authority

002

Budget Authority

003

Hiring and Budget Authority

999

Type of Authority Is Unknown



Shape213

Claims Files Valid Values

SERVICE-TRACKING-TYPE

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



Shape214

Claims Files Valid Values

SERVICING-PROV-NPI-NUM

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf





Shape215

Claims Files Valid Values

SERVICING-PROV-SPECIALTY

  • See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values.

Shape216

Claims Files Valid Values

SERVICING-PROV-TAXONOMY

http://www.wpc-edi.com/reference/



Shape217

Claims Files Valid Values

SOURCE-LOCATION

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

20

Managed Care Organization (MCO)

99

Unknown source



Shape218

Claims Files Valid Values

SPLIT-CLAIM-IND

0

No

1

Yes

9

Unknown



Shape219

Claims Files Valid Values

SSN-INDICATOR

0

State does not use SSN as MSIS-IDENTIFICATION-NUMBER

1

State uses SSN as MSIS-IDENTIFICATION-NUMBER



Shape220

Claims Files Valid Values

SUBMISSION-TRANSACTION-TYPE

C

Create File—a file that contains a complete set of transactions/changes processed since the last Create file submission. States may submit only one valid Create file per reporting period and data file type.

R

Replacement File—a Replacement submission is a replacement of the month’s data. It will completely replace the immediate prior submission. If a later replacement entry is received, it will overwrite the previous replacement, as well as a prior Create or Update submission for the same data type and reporting period.

U

Update File—a file that contains T-MSIS record segments created in response to business rule rejects. Note: The records in an Update file are not generated as a result of a change processed in the state’s Medicaid or Medicaid-related systems during the current reporting month. These Update file record segments may be unchanged from the ones submitted previously for various reasons (for example, the state may be unable to process a change record in their Medicaid / Medicaid-related systems to correct the issue because the state is simply passing through to T-MSIS data that originated outside of the state’s systems).[1] Conversely, the records may be different from those previously submitted, but the change is the result of a fix whose root cause problem was an issue in the T-MSIS file-creation or replacement process at CMS. Regardless, the record was not generated from a change that occurred in the state’s source data.

SUBMITTING-STATE

Shape221

Claims Files Valid Values


http://www.census.gov/geo/reference/ansi_statetables.html



Shape222

Claims Files Valid Values

TOOTH-DESIGNATION-SYSTEM

JO

ANSI/ADA/ISO Specification No. 3950

JP

ADA’s Universal/National Tooth Designation system



Shape223

Claims Files Valid Values

TOOTH-NUM




Primary Dentition:




Shape224

Claims Files Valid Values

TOOTH-QUAD-CODE

00

Entire Oral Cavity

01

Maxillary Area

02

Mandibular Area

03

Upper Right Sextant

04

Upper Anterior Sextant

05

Upper Left Sextant

06

Lower Left Sextant

07

Lower Anterior Sextant

08

Lower Right Sextant

09

Other Area of Oral Cavity (An area specified in an annexed document or further explanation available.)

10

Upper Right Quadrant (Right Refers to the oral and skeletal structures on the right side.)

20

Upper Left Quadrant (Left Refers to the oral and skeletal structures on the left side.)

30

Lower Left Quadrant

40

Lower Right Quadrant



Shape225

Claims Files Valid Values

TOOTH-SURFACE-CODE

B

Buccal – The surface of the tooth which is closest to the cheek.

D

Distal – The surface of the tooth facing away from an invisible line drawn vertically through the center of the face.

F

Facial – The surface of a tooth that is directed towards the face.

I

Incisal – The cutting edges of the anterior teeth.

L

Lingual – The surface of the tooth that is directed towards the tongue.

M

Mesial – The surface of a tooth which faces toward an invisible line drawn vertically through the center of the face.

O

Occlusa – The surfaces of the posterior (back) teeth which provides the chewing function.



Shape226

Claims Files Valid Values

TYPE-OF-BILL

2nd Digit-Type of Facility

1

Hospital

2

Skilled Nursing

3

Home Health

4

Religious Nonmedical (Hospital)

5

Reserved for national assignment (discontinued effective 10/1/05).

6

Intermediate Care

7

Clinic or Hospital Based Renal Dialysis Facility (requires special information in second digit below).

8

Special facility or hospital ASC surgery (requires special information in second digit below).

9

Reserved for National Assignment

3rd Digit-Bill Classification (Except Clinics and Special Facilities)

1

Inpatient

2

Inpatient

3

Outpatient

4

Other

5

Intermediate Care - Level I

6

Intermediate Care - Level II

7

Reserved for national assignment (discontinued effective 10/1/05).

8

Swing Bed (may be used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement).

9

Reserved for National Assignment

3rd Digit-Classification (Clinics Only)

1

Rural Health Clinic (RHC)

2

Hospital Based or Independent Renal Dialysis Facility

3

Free Standing Provider-Based Federally Qualified Health Center (FQHC)

4

Other Rehabilitation Facility (ORF)

5

Comprehensive Outpatient Rehabilitation Facility (CORF)

6

Community Mental Health Center (CMHC)

7-8

Reserved for National Assignment

9

OTHER

3rd Digit-Classification (Special Facilities Only)

1

Hospice (Nonhospital Based)

2

Hospice (Hospital Based)

3

Ambulatory Surgical Center Services to Hospital Outpatients

4

Free Standing Birthing Center

5

Critical Access Hospital

6-8

Reserved for National Assignment

9

OTHER

4th Digit-Frequency

A

Admission/Election Notice

B

Hospice/Medicare Coordinated Care Demonstration/Religious Nonmedical Health Care Institution Termination/Revocation Notice

C

Hospice Change of Provider Notice

D

Shape227

Claims Files Valid Values

Hospice/Medicare Coordinated Care Demonstration/Religious Nonmedical Health Care Institution Void/Cancel

E

Hospice Change of Ownership

F

Beneficiary Initiated Adjustment Claim

G

CWF Initiated Adjustment Claim

H

CMS Initiated Adjustment Claim

I

FI Adjustment Claim (Other than QIO or Provider

J

Initiated Adjustment Claim-Other

K

OIG Initiated Adjustment Claim

M

MSP Initiated Adjustment Claim

P

QIO Adjustment Claim

0

Nonpayment/Zero Claims

1

Admit Through Discharge Claim

2

Interim-First Claim

3

Interim-Continuing Claims (Not valid for PPS Bills)

4

Interim-Last Claim (Not valid for PPS Bills)

5

Late Charge Only

7

Replacement of Prior Claim

8

Void/Cancel of a Prior Claim

9

Final Claim for a Home Health PPS Episode



Shape228

Claims Files Valid Values

TYPE-OF-CLAIM

1

A Fee-For-Service Medicaid or Medicaid-expansion Claim

2

Medicaid or Medicaid-expansion Capitated Payment

3

Medicaid or Medicaid-expansion Managed Care 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.

4

Medicaid or Medicaid-expansion Service Tracking Claim

5

Medicaid or Medicaid-expansion Supplemental Payment (above capitation fee or above negotiated rate) (e.g., FQHC additional reimbursement)

A

Separate CHIP (Title XXI) claim: A Fee-for-Service Claim

B

Separate CHIP (Title XXI) claim: Capitated Payment

C

Separate 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

D

Separate CHIP (Title XXI) Service Tracking Claim

E

Separate CHIP (Title XXI) claim for a supplemental payment (above capitation fee or above negotiated rate) (e.g., FQHC additional reimbursement)

U

Other FFS claim

V

Other Capitated Payment

W

Other Managed Care Encounter

X

Non-Medicaid/CHIP service tracking claims

Y

Other Supplemental Payment

Z

Denied claims



Shape229

Claims Files Valid Values

TYPE-OF-HOSPITAL

00

Not a hospital

01

Inpatient Hospital

02

Outpatient Hospital

03

Critical Access Hospital

04

Swing Bed Hospital

05

Inpatient Psychiatric Hospital

06

IHS Hospital

07

Children’s Hospital

08

Other

99

Unknown



Shape230

Claims Files Valid Values

TYPE-OF-SERVICE

Source: http://www.ecfr.gov/cgi-bin/text-idx?SID=f37076abaf2eed6ee626fe4e69e7f9ce&tpl=/ecfrbrowse/Title42/42tab_02.tpl

TOS Code
(T-MSIS DD v 1.1)

TOS Description
(T-MSIS DD v 1.1)

FILE-NAME


001

Inpatient hospital services, other than services in an institution for mental diseases

CLAIMIP

002

Outpatient hospital services

CLAIMOT

003

Rural health clinic services

CLAIMOT

004

Other ambulatory services furnished by a rural health clinic

CLAIMOT

005

Professional laboratory services, Technical laboratory services

CLAIMOT

006

Technical laboratory services

CLAIMOT

007

Professional radiological services

CLAIMOT

008

Technical radiological services

CLAIMOT

009

Nursing facility services for individuals age 21 or older (other than services in an institution for mental disease)


CLAIMLT

010

Early and periodic screening and diagnosis and treatment (EPSDT) services

CLAIMOT

011

Family planning services and supplies for individuals of child-bearing age

CLAIMOT

CLAIMRX

012

Physicians' services

CLAIMOT

013

Medical and surgical services of a dentist

CLAIMOT

014

Outpatient substance abuse treatment services.

CLAIMOT

015

Medical or other remedial care or services, other than physicians' services, provided by licensed practitioners within the scope of practice as defined under State law

CLAIMOT

016

Home health services - Nursing services

CLAIMOT

017

Home health services - Home health aide services

CLAIMOT

018

Home health services - Medical supplies, equipment, and appliances suitable for use in the home

CLAIMOT

CLAIMRX

019

Home health services - Physical therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services

CLAIMOT

020

Home health services - Occupational therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services

CLAIMOT

021

Home health services - Speech pathology and audiology services provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services

CLAIMOT

022

Private duty nursing services

CLAIMOT

023

Advanced practice nurse services

CLAIMOT

024

Pediatric nurse

CLAIMOT

025

Nurse-midwife service

CLAIMOT

026

Nurse practitioner services

CLAIMOT

027

Respiratory care for ventilator-dependent individuals

CLAIMOT

028

Clinic services

CLAIMOT

029

Dental services

CLAIMOT

030

Physical therapy services (when not provided under home health services)

CLAIMOT

031

Occupational therapy services (when not provided under home health services)

CLAIMOT

032

Speech, hearing, and language disorders services (when not provided under home health services)

CLAIMOT

033

Prescribed drugs

CLAIMRX

034

Over-the-counter medications.

CLAIMRX

035

Dentures

CLAIMOT

036

Medical equipment/prosthetic devices

CLAIMOT

CLAIMRX

037

Eyeglasses

CLAIMOT

038

Hearing Aids

CLAIMOT

039

Diagnostic services

CLAIMOT

040

Screening services

CLAIMOT

041

Preventive services

CLAIMOT

042

Well-baby and well-child care services as defined by the State.

CLAIMOT

043

Rehabilitative services

CLAIMOT

044

Inpatient hospital services for individuals age 65 or older in institutions for mental diseases

CLAIMLT

045

Nursing facility services for individuals age 65 or older in institutions for mental diseases

CLAIMLT

046

Intermediate care facility (ICF/IIDICF/IID) services

CLAIMLT

047

Nursing facility services, other than in institutions for mental diseases

CLAIMLT

048

Inpatient psychiatric services for individuals under age 21

CLAIMLT

049

Outpatient mental health services, other than Outpatient substance abuse treatment services. This TOS includes services furnished in a State-operated mental hospital and including community-based services.

CLAIMOT

050

Inpatient substance abuse treatment services and residential substance abuse treatment services.

CLAIMLT

CLAIMOT

051

Personal care services

CLAIMOT

052

Primary care case management services

CLAIMOT

053

Targeted case management services

CLAIMOT

054

Case Management services other than those that meet the definition of primary care case management services or targeted case management services

CLAIMOT

055

Care coordination services

CLAIMOT

056

Transportation services

CLAIMOT

057

Enabling services

CLAIMOT

058

Services furnished in a religious nonmedical health care institution

CLAIMIP

059

Skilled nursing facility services for individuals under age 21

CLAIMLT

060

Emergency hospital services

CLAIMIP

CLAIMOT

061

Critical access hospital services - OT

CLAIMOT

062

HCBS - Case management services

CLAIMOT

063

HCBS - Homemaker services

CLAIMOT

064

HCBS - Home health aide services

CLAIMOT

065

HCBS - Personal care services

CLAIMOT

066

HCBS - Adult day health services

CLAIMOT

067

HCBS - Habilitation services

CLAIMOT

068

HCBS - Respite care services

CLAIMOT

069

HCBS - Day treatment or other partial hospitalization services, psychosocial rehabilitation services and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness

CLAIMOT

070

HCBS - Day Care

CLAIMOT

071

HCBS - Training for family members

CLAIMOT

072

HCBS - Minor modification to the home

CLAIMOT

073

HCBS - Other services requested by the agency and approved by CMS as cost effective and necessary to avoid institutionalization

CLAIMOT

074

HCBS - Expanded habilitation services - Prevocational services

CLAIMOT

075

HCBS - Expanded habilitation services - Educational services

CLAIMOT

076

HCBS - Expanded habilitation services - Supported employment services, which facilitate paid employment

CLAIMOT

077

HCBS-65-plus - Case management services

CLAIMOT

078

HCBS-65-plus - Homemaker services

CLAIMOT

079

HCBS-65-plus - Home health aide services

CLAIMOT

080

HCBS-65-plus - Personal care services

CLAIMOT

081

HCBS-65-plus - Adult day health services

CLAIMOT

082

HCBS-65-plus - Respite care services

CLAIMOT

083

HCBS-65-plus - Other medical and social services

CLAIMOT

084

Sterilizations

CLAIMIP

CLAIMOT

085

Prenatal care and pre-pregnancy family planning services and supplies.

CLAIMOT

CLAIMRX

086

Other Pregnancy-related Procedures

CLAIMIP

CLAIMOT

087

Hospice services

CLAIMOT

088

Any other health care services or items specified by the Secretary and not excluded under regulations.

CLAIMOT


089

Disposable medical supplies.

CLAIMOT

CLAIMRX

090

Critical access hospital services – IP

CLAIMIP

091

Skilled care – hospital residing

CLAIMIP

092

Exceptional care – hospital residing

CLAIMIP

093

Non-acute care – hospital residing

CLAIMIP

115

Residential care

CLAIMOT

119

Capitated payments to HMOs, HIOs, or PACE plans

CLAIMOT

120

Capitated payments for primary care case management (PCCM)

CLAIMOT

121

Premium payments for private health insurance

CLAIMOT

122

Capitated payments to prepaid health plans (PHPs)

CLAIMOT

123

Disproportionate share hospital (DSH) payments

CLAIMIP

CLAIMOT

127

Indian Health Service (IHS) - Family Plan

CLAIMOT

CLAIMRX

131

Drug Rebates

CLAIMOT

CLAIMRX

132

Supplemental payment - inpatient

CLAIMIP

133

Supplemental payment - nursing

CLAIMLT

134

Supplemental payment - outpatient

CLAIMOT

135

EHR payments to provider

CLAIMIP

CLAIMOT

Shape232 Shape231

Claims Files Valid Values

Claims Files Valid Values

UNDER-DIRECTION-OF-PROV-NPI

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf



Shape233

Claims Files Valid Values

UNDER-DIRECTION-OF-PROV-TAXONOMY

http://www.wpc-edi.com/reference/



Shape234

Claims Files Valid Values

UNDER-SUPERVISION-OF-PROV-NPI

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npicheckdigit.pdf



Shape235

Claims Files Valid Values

UNDER-SUPERVISION-OF-PROV-TAXONOMY

http://www.wpc-edi.com/reference/



Shape236

Claims Files Valid Values

UNIT-OF-MEASURE

F2

International Unit

ML

Milliliter

GR

Gram

UN

Unit



Shape237

Claims Files Valid Values

WAIVER-TYPE

01

1115 other 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) – Aged and Disabled

07

1915(c) – Aged

08

1915(c) – Physical Disabilities

09

1915(c) – Intellectual Disabilities

10

1915(c) – Intellectual and Developmental Disabilities

11

1915(c) – Brain Injury

12

1915(c) – HIV/AIDS

13

1915(c) – Technology Dependent or Medically Fragile

14

1915(c) –Disabled (other)

15

1915(c) - Enrolled in 1915(c) waiver for unspecified or unknown populations

16

1915(c) - Autism/Autism spectrum disorder

17

1915(c) – Developmental Disabilities

18

1915(c) – Mental Illness - Age 18 or Older

19

1915(c) – Mental Illness - Under Age 18

20

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)

21

1115 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.

22

1115 Pharmacy Plus 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.

23

1115 Disaster-Related Waiver – The associated Waiver-ID is for a disaster-related waiver that allows for coverage related to a hurricane or other disaster.

24

1115 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 or CHIP, but is NOT enrolled in a waiver.

99

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





Shape238

Claims Files Valid Values

XIX-MBESCBES-CATEGORY-OF-SERVICE

See Appendix I: MBES CBES Category of Service Line Definitions for the 64.9 Base Form for listing of valid values.





Shape239

Claims Files Valid Values

XXI-MBESCBES-CATEGORY-OF-SERVICE

See Appendix J: MBES CBES Category of Service Line Definitions for the 21 Form for listing of valid values.





Appendix B: Home and Community-Based Services (HCBS) Taxonomy

The following table defines categories and services in the HCBS Taxonomy. It was approved by CMS in August 2012.

To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting.

Some of the services reflected below, including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as “extended state plan” services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment.

The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state’s service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc.

HCBS Service Taxonomy Values:

Category

Sub-Category (where applicable)

Service

Common Names

(where applicable)

Definition

01 – Case Management

 

 

 

The development of a comprehensive, written individualized support plan. In addition, case management often includes assisting people in gaining access to necessary services, assessment of a person's needs, ongoing monitoring of service provision and/or a person's health and welfare, assistance in accessing supports to transition from an institutional setting (but not the transition services themselves); and development of a 24-hour individual back-up plan with formal and informal supports

 

01010 case management

 

care management
supports coordination

Same definition as category 01.

02 Round-the-Clock Services

 

 

 

Services by a provider that has round-the-clock responsibility for the health and welfare of residents, except during the time other services (e.g., day services) are furnished. If these services are provided in a 1915(c) waiver, the state must complete Appendix G-3 of the 1915(c) waiver application regarding medication management and administration.

 

0201 group living

 

assisted living
group home services

Round-the-clock services provided in a residence that is NOT a person’s home or apartment or a single family residence where one or more people with a disability live with a person or family who furnishes services

 

 

02011 group living, residential habilitation

 

Assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills by a provider with round-the-clock responsibility for the residents’ health and welfare in a residence that is NOT a person’s own home or apartment or a single family residence where one or more people with a disability live with a person or family who furnishes services.

 

 

02012 group living, mental health services

 

Mental health services by a provider with round-the-clock responsibility for the residents’ health and welfare in a residence that is NOT a person’s own home or apartment or a single family residence where one or more people with a disability live with a person or family who furnishes services.

 

 

02013 group living, other

 

Health and social services not identified elsewhere in subcategory 0201 by a provider with round-the-clock responsibility for the residents’ health and welfare in a residence that is NOT a person’s own home or apartment or a single family residence where one or more people with a disability live with a person or family who furnishes services.

 

0202 shared living

 

adult foster care
family living
host homes

Round-the-clock services provided in a single family residence where one or more people with a disability live with a person or family who furnishes services.

 

 

02021 shared living, residential habilitation

 

Assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills provided in a single family residence where one or more people with a disability live with a person or family who furnishes services and has round-the-clock responsibility for the residents’ health and welfare.

 

 

02022 shared living, mental health services

 

Mental health services provided in a single family residence where one or more people with a disability live with a person or family who furnishes services and has round-the-clock responsibility for the residents’ health and welfare.

 

 

02023 shared living, other

 

Health and social services not identified elsewhere in subcategory 0202 provided in a single family residence where one or more people with a disability live with a person or family who furnishes services and has round-the-clock responsibility for the residents’ health and welfare.

 

0203 in-home round-the-clock services

 

supported living

Round-the-clock services provided in a person's home or apartment where a provider has round-the-clock responsibility for the person's health and welfare.

 

 

02031 in-home residential habilitation

 

Assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills provided in a person's home or apartment where a provider has round-the-clock responsibility for the person's health and welfare.

 

 

02032 in-home round-the-clock mental health services

 

Mental health services provided in a person's home or apartment where a provider has round-the-clock responsibility for the person's health and welfare.

 

 

02033 in-home round-the-clock services, other

 

Health and social services not identified elsewhere in subcategory 0203 provided in a person's home or apartment where a provider has round-the-clock responsibility for the person's health and welfare.

03 Supported Employment

 

 

 

Assistance to help a person obtain or maintain paid employment or self-employment.

 

0301 job development

03010 job development

 

Assistance to locate and obtain paid employment or self-employment.

 

0302 ongoing supported employment

 

 

Assistance to maintain paid employment or self-employment.

 

 

03021 ongoing supported employment, individual

 

Assistance to maintain self-employment or paid employment in an individual job placement (i.e., person is working with people without disabilities).

 

 

03022 ongoing supported employment, group

 

Assistance to maintain paid employment in a group placement (i.e., person is working on a team of people with disabilities).

 

0303 career planning

03030 career planning

 

Focused, time-limited assistance to identify a career direction and develop a plan to achieve employment.

04 Day Services

 

 

 

Services other than supported employment typically provided outside the person's home during the working day (i.e., Monday through Friday between 8 a.m. and 5 p.m.). These services provide a range of supports and are often, but not always, provided on a regularly scheduled basis at a site specifically established to provide day services.

 

 

04010 prevocational services

 

Time-limited services to provide learning and work experiences, including volunteer work, to acquire general skills that help a person obtain paid employment in integrated community settings.

 

 

04020 day habilitation

 

Regularly scheduled activities in settings separate from the participant’s residence, including assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills. This service includes community-based volunteer activities that include acquiring, retaining, and improving self-help, socialization, and adaptive skills. This service can include the supports offered in adult day health, adult day services (social model), and community integration if these supports are provided along with assistance in acquiring, retraining, and improving self-help, socialization, and/or adaptive skills.

 

 

04030 education services

 

Services to help a person access post-secondary education.

 

 

04040 day treatment/ partial hospitalization

 

Services necessary for the diagnosis or treatment of the person's mental illness provided in a fixed site facility during the working day.

 

 

04050 adult day health

 

Skilled health services and other support services, NOT including habilitation (i.e., assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills), provided to adults in a fixed site facility during the working day. This service can include the supports offered in adult day services (social model) if these supports are provided along with skilled health services.

 

 

04060 adult day services (social model)

 

Support services, NOT including skilled health services and not including habilitation (i.e., assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills), provided to adults in a fixed site facility during the working day.

 

 

04070 community integration

escort

Assistance in participating in community activities, NOT including assistance with activities of daily living or assistance in acquiring, retraining, and improving self-help, socialization, and/or adaptive skills. This service can include supports furnished in the person’s residence related to community participation.

 

 

04080 medical day care for children

 

Medical services beyond typical day care responsibilities provided during the working day for infants, toddlers, and pre-school age children.

05 Nursing

 

 

 

Services within the scope of the state's nurse practices act provided by a licensed nurse.

 

 

05010 private duty nursing

 

Licensed nursing services provided on a continuous or full-time basis (e.g., for more than 4 consecutive hours per day and for more than 60 days). This service can include the supports offered in health assessment, health monitoring, and medication assessment if the service also includes other services within the scope of the state’s nurse practices act.

 

 

05020 skilled nursing

 

Licensed nursing services provided on a part-time or intermittent basis. This service can include the supports offered in health assessment, health monitoring, and medication assessment if the service also includes other services within the scope of the state’s nurse practices act.

06 Home delivered meals

 

 

 

Prepared meals sent to a person's home, which may not comprise a full nutritional regimen.

 

 

06010 home delivered meals

 

Same definition as category 06.

07 Rent and Food Expenses for Live-In Caregiver

 

 

 

Payment for the additional costs of rent and food that can be attributed to an unrelated direct support worker living with the person. This service does not include payment for the direct support worker’s services, which may be covered as part of other services such as personal care.

 

 

07010 rent and food expenses for live-in caregiver

 

Same definition as category 07.

08 Home-Based Services

 

 

 

Services that support a person in his or her home or apartment, when the provider does not have round-the-clock responsibility for the person's health and welfare. These services can be provided in other community settings, but are primarily furnished in a person’s home or apartment.

 

 

08010 home-based habilitation

supported living (provided on an hourly basis)

Assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills provided in the person's home when the provider does NOT have round-the-clock responsibility for the person's health and welfare. This service can include the supports offered in community integration, home health aide, personal care, companion, and homemaker if these supports are provided along with assistance in acquiring, retraining, and improving self-help, socialization, and/or adaptive skills.

 

 

08020 home health aide

 

Assistance with activities of daily living (ADLs) and/or health-related tasks provided in a person's home and possibly other community settings that are supervised by a registered nurse or licensed therapist and provided by a licensed home health agency. Home health aide may include assistance with instrumental activities of daily living (IADLs). Home health aide may include the supports offered in companion and homemaker if these supports are provided along with assistance with ADLs and/or health-related tasks. Home health aide does NOT include habilitation (assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills).

 

 

08030 personal care

attendant care
personal assistance
personal attendant services

Assistance with ADLs and/or health-related tasks provided in a person's home and possibly other community settings, NOT including both provision by a licensed home health agency and a requirement for supervision by a licensed nurse or therapist. Personal care may include assistance with IADLs. Personal care may include the supports offered in companion and homemaker if these supports are provided along with assistance with ADLs and/or health-related tasks. Personal care does NOT include habilitation (assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills).

 

 

08040 companion

adult companion
night supervision

Supervision and/or social support provided in a person's home and possibly other community settings. Companion may also include performance of light housekeeping tasks (the supports offered in homemaker). Companion does NOT include assistance with ADLs or habilitation (assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills).

 

 

08050 homemaker

 

Performance of light housekeeping tasks provided in a person's home and possibly other community settings NOT including supervision and social support, assistance with ADLs, or habilitation (assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills).

 

 

08060 chore

 

Performance of heavy household chores provided in a person's home and possibly other community settings NOT including supervision and social support, assistance with ADLs, or habilitation (assistance in acquiring, retaining, and improving self-help, socialization, and/or adaptive skills).

09 Caregiver Support

 

 

 

Assistance to people who provide ongoing support to the person with a disability when assisting the support person is the primary purpose of the service. In most cases, the support person is unpaid. However, respite can be provided to relieve providers who furnish shared living.

 

0901 respite

 

 

Short-term services provided because a support person is absent or needs relief when relieving the support person is the primary purpose of the service.

 

 

09011 respite, out-of-home

 

Short-term services provided because a support person is absent or needs relief NOT provided in a person's home or apartment when relieving the support person is the primary purpose of the service.

 

 

09012 respite, in-home

 

Short-term services provided because a support person is absent or needs relief provided in a person's home or apartment when relieving the support person is the primary purpose of the service.

 

0902 caregiver counseling and/or training

09020 caregiver counseling and/or training

 

Counseling, emotional support, and/or training provided to a family member or friend providing support when providing counseling or training to the support person is the primary purpose of the service. Examples of training topics include a) skills to provide specific treatment regimens or help the person improve function, b) information about the person's disability or conditions, and c) navigation of the service system.

10 Other Mental Health and Behavioral Services

 

 

 

Services NOT identified in previous categories that support people in improving or maintaining mental or behavioral health.

 

 

10010 mental health assessment

 

Assessment or evaluation of mental health status when the assessment is the primary purpose of the service. This service can include medication assessment if the assessment includes other mental health information.

 

 

10020 assertive community treatment

 

A range of mental health supports characterized by assertive engagement of the person, availability 24 hours a day, and support by an interdisciplinary team.

 

 

10030 crisis intervention

crisis support

Response to stabilize a person exhibiting behavior that puts the person at risk of hospitalization or institutionalization.

 

 

10040 behavior support

behavior analysis
behavior therapy

Services specifically to encourage positive behaviors and to decrease challenging behaviors, including a) assessment to identify antecedents to behaviors and b) development of a plan to improve behaviors.

 

 

10050 peer specialist

peer support

Mental health support services provided by a trained and credentialed person with a mental illness.

 

 

10060 counseling

 

Individual or group therapy to develop coping skills or improve mental health function.

 

 

10070 psychosocial rehabilitation

 

Assistance to improve or restore function in ADLs, IADLs, and social or adaptive skills NOT identified in previous categories or services.

 

 

10080 clinic services

 

Services for individuals with chronic mental illness furnished in a clinic or based in a clinic NOT identified in previous categories or services.

 

 

10090 other mental health and behavioral services

 

Services NOT identified elsewhere in category 10 that support people in improving or maintaining mental or behavioral health.

11 Other Health and Therapeutic Services

 

 

 

Services NOT identified in previous categories that support people in improving or maintaining health or functional capacity.

 

 

11010 health monitoring

 

Ongoing monitoring of physical health status when monitoring is the primary purpose of the service. This service can include medication monitoring if other aspects of a person’s health also are monitored.

 

 

11020 health assessment

 

Assessment or evaluation of physical health status when the assessment is the primary purpose of the service. This service can include medication assessment if the assessment includes other health information.

 

 

11030 medication assessment and/or management

 

Assessment of medication administration and/or possible drug interactions—and/or oversight of ongoing medication administration—when the management of medications is the primary purpose of the service.

 

 

11040 nutrition consultation

 

Assistance to a person to help him or her plan and implement changes to nutritional intake.

 

 

11050 physician services

 

Services by a licensed physician. This service can include health assessment, medication assessment, and/or mental health assessment if other physician services are also provided.

 

 

11060 prescription drugs

 

Prescription drugs.

 

 

11070 dental services

 

Services by a licensed dentist.

 

 

11080 occupational therapy

 

Services by a licensed occupational therapist.

 

 

11090 physical therapy

 

Services by a licensed physical therapist.

 

 

11100 speech, hearing, and language therapy

 

Services by a licensed speech, hearing, and language therapist. This service includes services by a speech pathologist or a qualified audiologist.

 

 

11110 respiratory therapy

 

Services by a licensed respiratory therapist.

 

 

11120 cognitive rehabilitative therapy

 

Assistance to manage or restore cognitive function.

 

 

11130 other therapies

 

Therapeutic interventions to maintain or improve function NOT identified in previous categories or services. This service includes specialized interventions such as those using art, music, dance, or trained animals.

12 Services Supporting Participant Direction

 

 

 

Services that assist a person and/or his or her representative in managing participant-directed services, as identified in the Participant Direction of Services section of the 1915(c) waiver or 1915(i) State Plan Amendment application.

 

 

12010 financial management services in support of participant direction

 

Assistance to help a person and/or representative manage participant-directed services by a) performing financial tasks to facilitate the employment of staff; b) managing the disbursement of funds in a participant-directed budget; and/or c) performing fiscal accounting and making expenditure reports to the person, representative, and/or state authorities.

 

 

12020 information and assistance in support of participant direction

 

Training the person and/or representative in directing or managing services. Topics include: a) the person's rights and responsibilities in participant direction; b) recruiting and hiring staff; c) managing staff and solving problems regarding services; and d) managing a participant-directed budget.

13 Participant Training

 

 

 

Training provided to a participant when training the participant is the primary purpose of the service. Topics may include: a) specific treatment regimens, b) the person's disability or condition, and c) navigation of the service system.

 

 

13010 participant training

 

The same definition as category 13.

14 Equipment, Technology, and Modifications

 

 

 

Material goods to help a person improve or maintain function.

 

1401 personal emergency response system (PERS)

14010 personal emergency response system (PERS)

 

Devices that enable participants to signal a response center to secure help in an emergency. This service can include installation, maintenance, and monthly response center fees.

 

1402 home and/or vehicle accessibility adaptations

14020 home and/or vehicle accessibility adaptations

home and/or vehicle modifications

Physical changes to a private residence, automobile, or van, to accommodate the participant or improve his or her function.

 

1403 equipment, technology, and supplies

 

 

The purchase or rent of items, devices, product systems, and/or disposable medical supplies.

 

 

14031 equipment and technology

assistive technologyspecialized medical equipment

The purchase or rent of items, devices, or product systems to increase or maintain a person's functional status. This service can include designing, fitting, adapting, and maintaining equipment, as well as training or technical assistance to use equipment.

 

 

14032 supplies

 

The purchase of disposable medical supplies, including nutritional supplements.

15 Non-Medical Transportation

 

 

 

Transportation not provided as part of another service such as a round-the-clock service or a day service. This service may include: a) transportation to and from other HCBS services; b) transportation to community activities where HCBS services are not provided; and/or c) the purchase of public transit tokens or passes.

 

 

15010 non-medical transportation

 

Same definition as category 15.

16 Community Transition Services

 

 

 

Non-recurring set-up expenses for moving to a residence where the person is responsible for living expenses.

 

 

16010 community transition services

 

Same definition as category 16.

17 Other Services

 

 

 

Services NOT identified in previous categories.

 

 

17010 goods and services

Individually directed goods and services

Services, equipment, or supplies in the person's support plan NOT otherwise provided in the Medicaid program.

 

 

17020 interpreter

 

Services provided by an individual to support communication by someone who has limited English proficiency or verbal skills, such as a sign language interpreter or communicator.

 

 

17030 housing consultation

 

Information and assistance to help a person identify and select housing.

 

 

17990 other

 

Services NOT identified in previous categories and services.





Appendix C: Comprehensive Eligibility Crosswalk


MAS/BOE - INDIVIDUALS COVERED UNDER SEPARATE CHILDREN’S HEALTH INSURANCE PROGRAMS

(Separate-CHIP)


ITEM

DESCRIPTION

CFR/PL CITATIONS

1

Children covered under a Title XXI separate CHIP)

42 CFR 457.310, §2110 (b) of the Act.

2

Legal immigrant children and pregnant women covered under a Title XXI separate CHIP

§2107(e)(1) of the Act, P.L. 111-3.

3


Children receiving dental-only coverage under a separate CHIP

§2102 and 2110 (b) of the Act, PL 111-3.


4

Targeted low-income pregnant women covered under a Title XXI separate 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 separate CHIP

§2112 of the Act, PL 111-3.


6

Children who have been granted presumptive eligibility under a Title XXI separate CHIP

42 CFR 457.355, §2105 of the Act.


7

Pregnant women who have been granted presumptive eligibility under a Title XXI separate 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 separate 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

1

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.

2

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

1

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.

2

  1. Pregnant women who have no other eligible children.

  2. 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

1

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.

2

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

1

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.

2

  1. Pregnant women who have no other eligible children.

  2. 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

1

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.

2

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

1

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

1

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

1

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

1

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).





Appendix D: Types of Service (TOS) 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 (TOS Code=001)(See 42 CFR 440.10; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 health conditions;


- 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 health conditions is a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis, treatment or care of individuals with mental health conditions, 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 (TOS Code=048)(See 42 CFR 440.160; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450). --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) (TOS Code= 044 and 045)(See 42 CFR 440.140).--These are services provided under the direction of a physician for the care and treatment of recipients in an institution for mental health conditions that meets the requirements specified in 42 CFR 440.140.



4. Nursing Facilities (NF) Services(TOS Code=009 and 047)(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 health conditions; 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 Intellectually Disabled (TOS Code=046) (See 42 CFR 440.150).--These are services provided in an institution for individuals with intellectual disabilities 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/IID); and


o The individuals with intellectual disabilities recipients for whom payment is requested are receiving active treatment as defined in 42 CFR 483.440(a).


Physicians' Services (TOS Code=012)(See 42 CFR 440.50; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Codes=002)(See 42 CFR 440.20; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=033)(See 42 CFR 440.120; 42 CFR § 457.402; 42 CFR § 457.410; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=029)(See 42 CFR 440.100; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=015)(See 42 CFR 440.60; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=028(See 42 CRF 440.90; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=005, 006, 007, and 008)(See 42 CFR 440.30; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=084)(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 (TOS Code=016,017, 018, 019, 020, and 021) (See 42 CFR 440.70; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=051)(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 individuals with intellectual disabilities, or institution for mental health conditions 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 (TOS Code=053)(See 42 CFR § 440.169; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=043)(See 42 CFR 440.130).--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 health condition 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 (TOS Codes=030, 031, and 032)(See 42 CFR 440.110; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=087)(See 42 CFR 418.202; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=025)(See 42 CFR 440.165; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=026)(See 42 CFR 440.166; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=022)(See 42 CFR 440.80; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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 (TOS Code=058)(See 42 CFR 440.170).--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 (TOS Code=056)(See 42 CFR 440.170; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--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. Other Pregnancy-related Procedures (TOS Code=086)(See 42 CFR 441, Subpart E; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--In accordance with the terms of the DHHS Appropriations Bill and 42 CFR 441, Subpart E, FFP is available for other pregnancy-related procedures:


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 other pregnancy-related procedure is performed to terminate a pregnancy resulting from an act of rape or incest. FFP is not available for the other pregnancy-related procedure under any other circumstances.


16c. Other Services (TOS Code= 035, 036, 037, 062, 063, 064, 065, 066, 067, 068, 069, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083).--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; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450) 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; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450). 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) (TOS Code=119).--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) (TOS Code=122).--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) (TOS Code=120)(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).



Appendix E: Program Type Reference


The following definitions describe special Medicaid/CHIP 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 01. 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 02. 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 03. 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 04. 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 05. 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 06. Home and Community-Based Services for Disabled and 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 07. 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).


Program Type 08. Money Follows Patient (MFP) service package (established by Section 6071 of Deficit Reduction Act of 2005 [Public Law 109-171] and extended by Section 2403 off the Patient Protection and Affordable Care Act of 2010 [Public Law 111-148]) helps States rebalance their long-term care systems through the development of transition programs that move people with Medicaid from institutional-based long-term care to community-based long-term care. To qualify for MFP, Medicaid recipients need to have been in institutional care for at least 90 days, exclusive of Medicare-paid rehabilitation days. Upon the initial transition to community-based long-term care, MFP participants are eligible for MFP benefits for up to 365 days. At the conclusion of MFP eligibility, the person continues as a typical Medicaid beneficiary. While eligible for MFP benefits, the restricted benefits flag in the eligibility file should be set to value 08 whenever the beneficiary has a single day of MFP eligibility during the month.

Any service financed with MFP grant funds is considered an MFP service. MFP services are home- and community-based services (HCBS) financed with MFP grant funds. They can be 1915(c) waiver services or HCBS state plan services. The program has three classes of HCBS, including qualified HCBS (HCBS that the person would have been eligible for regardless of participation in MFP), demonstration HCBS (HCBS that are above and beyond what they would have qualified for as a regular Medicaid beneficiary), and supplemental services (which are typically one-time services someone needs to make the transition to community-based long-term care). States received enhanced matching funds for the qualified and demonstration services, and their regular mating rate for the supplemental services. Examples of MFP-financed services include, but are not limited to:


  • 1915(c) waiver services

  • Personal care assistance services provided through the state plan

  • Behavioral health services, including psychosocial rehabilitation


Program Type 10. Balancing Incentive Payments (BIP). The Balancing Incentive Program authorizes grants to States to increase access to non-institutional long-term services and supports (LTSS) as of October 1, 2011.

The Balancing Incentive Program will help States transform their long-term care systems by:

Lowering costs through improved systems performance & efficiency

Creating tools to help consumers with care planning & assessment

Improving quality measurement & oversight

The Balancing Incentive Program also provides new ways to serve more people in home and community-based settings, in keeping with the integration mandate of the Americans with Disabilities Act (ADA), as required by the Olmstead decision. The Balancing Incentive Program was created by the Affordable Care Act of 2010 (Section 10202).


Program Type 11.Community First Choice (1915(k). The “Community First Choice Option” lets States provide home and community-based attendant services to Medicaid enrollees with disabilities under their State Plan.

This option became available on October 1, 2011 and provides a 6 % increase in Federal matching payments to States for expenditures related to this option.


Program Type 12. Psychiatric Rehab Facility For Children. Under the authority of section 2707 of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), the Centers for Medicare & Medicaid Services (CMS) is funding the Medicaid Emergency Psychiatric Demonstration, which will be conducted by participating States. This is a 3-year Demonstration that permits participating States to provide payment under the State Medicaid plan to certain non-government psychiatric hospitals for inpatient emergency psychiatric care to Medicaid recipients aged 21 to 64 who have expressed suicidal or homicidal thoughts or gestures, and are determined to be dangerous to themselves or others.


Program Type 13. Home and Community-Based Services (HCBS) State Plan Option (1915(i)). States can offer a variety of services under a State Plan Home and Community-Based Services (HCBS) benefit. People must meet State-defined criteria based on need and typically get a combination of acute-care medical services (like dental services, skilled nursing services) and long-term services (like respite, case management, supported employment and environmental modifications).

1915(i) State plan HCBS: State Options

Target the HCBS benefit to one or more specific populations

Establish separate additional needs-based criteria for individual HCBS

Establish a new Medicaid eligibility group for people who get State plan HCBS

Define the HCBS included in the benefit, including State- defined and CMS-approved “other services” applicable to the population

Option to allow any or all HCBS to be self-directed


Program Type 14.State Plan CHIP (See 42 CRF 457) ‘This program is for Title XXI recipients (children age 0 through 18, children receiving prenatal care through the conception to birth option, pregnant women), “Child health assistance” services (as allowed by State law and defined at § 457.402) means payment for part or all of the cost of health benefits coverage provided to targeted low-income children for the following services:

(a) Inpatient hospital services.


(b) Outpatient hospital services.


(c) Physician services.


(d) Surgical services.


(e) Clinic services (including health center services) and other ambulatory health care services.


(f) Prescription drugs and biologicals and the administration of these drugs and biologicals, only if these drugs and biologicals are not furnished for the purpose of causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a person.


(g) Over-the-counter medications.


(h) Laboratory and radiological services.


(i) Prenatal care and pre-pregnancy family planning services and supplies.

(j) Inpatient mental health services, other than services described in paragraph (r) of this section but including services furnished in a state-operated mental health hospital and including residential or other 24-hour therapeutically planned structured services.


(k) Outpatient mental health services, other than services described in paragraph (s) of this section but including services furnished in a State-operated mental health hospital and including community-based services.


(l) Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices and adaptive devices).


(m) Disposable medical supplies.


(n) Home and community-based health care services and related supportive services (such as home health nursing services, personal care, assistance with activities of daily living, chore services, day care services, respite care services, training for family members and minor modification to the home.)


(o) Nursing care services (such as nurse practitioner services, nurse midwife services, advanced practice nurse services, private duty nursing, pediatric nurse services and respiratory care services) in a home, school, or other setting.


(p) Other pregnancy-related procedure only if necessary to save the life of the mother or if the pregnancy is the result of rape or incest.


(q) Dental services.


(r) Inpatient substance abuse treatment services and residential substance abuse treatment services.


(s) Outpatient substance abuse treatment services.


(t) Case management services.


(u) Care coordination services.


(v) Physical therapy, occupational therapy, and services for individuals with speech, hearing and language disorders.


(w) Hospice care.


(x) Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (whether in a facility, home, school, or other setting) if recognized by State law and only if the service is—


(1) Prescribed by or furnished by a physician or other licensed or registered practitioner within the scope of practice as defined by State law;


(2) Performed under the general supervision or at the direction of a physician; or


(3) Furnished by a health care facility that is operated by a State or local government or is licensed under State law and operating within the scope of the license.


(y) Premiums for private health care insurance coverage.


(z) Medical transportation.


(aa) Enabling services (such as transportation, translation, and outreach services) only if designed to increase the accessibility of primary and preventive health care services for eligible low-income individuals.


(bb) Any other health care services or items specified by the Secretary and not excluded under this subchapter.


Program Type 15. Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF). The Community Alternatives to Psychiatric Residential Treatment Facilities (PRTF) Demonstration Grant Program was authorized by Section 6063 of the Deficit Reduction Act of 2005 to provide up to $218 million to up to 10 states to develop 5-year demonstration programs that provide home and community-based services to children as alternatives to PRTF's. Nine states implemented demonstration grants. These projects were designed to test the cost-effectiveness of providing services in a child’s home or community rather than in a PRTF and whether the services improve or maintain the child’s functioning.


Program Type 16. 1915(j) (Self-directed personal assistance services/personal care under State Plan or 1915(c) waiver). Self-directed personal assistance services (PAS) are personal care and related services provided under the Medicaid State plan and/or section 1915(c) waivers the State already has in place.

Participation in self-directed PAS is voluntary

Participants set their own provider qualifications and train their PAS providers Participants determine how much they pay for a service, support or item



Appendix F: Eligibility Group Table

Code

Eligibility Group

Short Description

Citation

Type

Category

MEDICAID 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.

42 CFR 435.110; 1902(a)(10)(A)(i)(I); 1931(b) and (d)

Family/Adult

Mandatory Coverage

02

Transitional Medical Assistance

Families with Medicaid eligibility extended for up to 12 months because of earnings.

408(a)(11)(A); 1902(a)(52); 1902(e)(1)(B);
1925;
1931(c)(2)

Family/Adult

Mandatory Coverage

03

Extended Medicaid due to Earnings

Families with Medicaid eligibility extended for 4 months because of increased earnings.

42 CFR 435.112; 408(a)(11)(A); 1902 (e)(1)(A);
1931 (c)(2)

Family/Adult

Mandatory Coverage

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.

42 CFR 435.115; 408(a)(11)(B); 1931 (c)(1)

Family/Adult

Mandatory Coverage

05

Pregnant Women

Women who are pregnant or post-partum, with household income at or below a standard established by the state.

42 CFR 435.116; 1902(a)(10)(A)(i)(III) and (IV); 1902(a)(10)(A)(ii)(I), (IV) and (IX);
1931(b) and (d);

Family/Adult

Mandatory Coverage

06

Deemed Newborns

Children born to women covered under Medicaid or a separate CHIP for the date of the child's birth, who are deemed eligible for Medicaid until the child turns age 1

42 CFR 435.117;
1902(e)(4) and 2112€

Family/Adult

Mandatory Coverage

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.

42 CFR 435.118 1902(a)(10)(A)(i)(III), (IV), (VI) and (VII); 1902(a)(10)(A)(ii)(IV) and (IX); 1931(b) and (d)

Family/Adult

Mandatory Coverage

08

Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care

Individuals for whom an adoption assistance agreement is in effect or foster care or kinship guardianship assistance maintenance payments are made under Title IV-E of the Act.

42 CFR 435.145; 473(b)(3); 1902(a)(10)(A)(i)(I)

Family/Adult

Mandatory Coverage

09

Former Foster Care Children

Individuals under the age of 26, not otherwise mandatorily eligible, who were in foster care and on Medicaid either when they turned age 18 or aged out of foster care.

42 CFR 435.150;
1902(a)(10)(A)(i)(IX)

Family/Adult

Mandatory Coverage

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.

42 CFR 435.119; 1902(a)(10)(A)(i)(VIII)

Family/Adult

Mandatory Coverage

Please note that T-MSIS eligibility grouping # 10 “Individuals at or below 133% FPL Age 19 through 64” has been removed and replaced with expanded groupings 72-75 (see below).

72

Adult Group - Individuals at or below 133% FPL Age 19 through 64 - newly eligible for all states

Non-pregnant individuals aged 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.

42 CFR 435.119; 1902(a)(10)(A)(i)(VIII)

Family/Adult

Mandatory Coverage

73

Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible for non 1905z(3) states

Non-pregnant individuals aged 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.

42 CFR 435.119; 1902(a)(10)(A)(i)(VIII) 1905z(3)

Family/Adult

Mandatory Coverage

74

Adult Group - Individuals at or below 133% FPL Age 19 through 64 – not newly eligible parent/ caretaker-relative(s) in 1905z(3) states

Non-pregnant individuals aged 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.

42 CFR 435.119; 1902(a)(10)(A)(i)(VIII)

1905z(3)

Family/Adult

Mandatory Coverage

75

Adult Group - Individuals at or below 133% FPL Age 19 through 64- not newly eligible non-parent/ caretaker-relative(s) in 1905z(3) states

Non-pregnant individuals aged 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.

42 CFR 435.119; 1902(a)(10)(A)(i)(VIII)

1905z(3)

Family/Adult

Mandatory Coverage

11

Individuals Receiving SSI

Individuals who are aged, blind or disabled who receive SSI.

42 CFR 435.120; 1902(a)(10)(A)(i)(II)(aa)

ABD

Mandatory Coverage

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.

42 CFR 435.121; 1902(f)

ABD

Mandatory Coverage

13

Individuals Receiving Mandatory State Supplements

Individuals receiving mandatory State Supplements to SSI benefits.

42 CFR 435.130

ABD

Mandatory Coverage

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.

42 CFR 435.131; 1905(a)

ABD

Mandatory Coverage

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.

42 CFR 435.132

ABD

Mandatory Coverage

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.

42 CFR 435.133

ABD

Mandatory Coverage

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.

42 CFR 435.134

ABD

Mandatory Coverage

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.

42 CFR 435.135;

ABD

Mandatory Coverage

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.

42 CFR 435.137; 1634(b)

ABD

Mandatory Coverage

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.

42 CFR 435.138; 1634(d)

ABD

Mandatory Coverage

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.

1619(b); 1902(a)(10)(A)(i)(II)(bb); 1905(q)

ABD

Mandatory Coverage

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.

1634(c)

ABD

Mandatory Coverage

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.

1902(a)(10)(E)(i); 1905(p)

ABD

Mandatory Coverage

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.

1902(a)(10)(E)(ii); 1905(p)(3)(A)(i); 1905(s)

ABD

Mandatory Coverage

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 B premiums.

1902(a)(10)(E)(iii); 1905(p)(3)(A)(ii)

ABD

Mandatory Coverage

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.

1902(a)(10)(E)(iv); 1905(p)(3)(A)(ii)

ABD

Mandatory Coverage

MEDICAID 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.

42 CFR 435.220; 1902(a)(10)(A)(ii)(I)

Family/Adult

Options for Coverage

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.

42 CFR 435.222; 1902(a)(10)(A)(ii)(I) and (IV)

Family/Adult

Options for Coverage

29

Children with Non-IV-E Adoption Assistance

Children with special needs for whom there is a non-IV-E adoption assistance agreement in effect with a state, who either were eligible for Medicaid or had income at or below a standard established by the state.

42 CFR 435.227; 1902(a)(10)(A)(ii)(VIII);

Family/Adult

Options for Coverage

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.

42 CFR 435.226; 1902(a)(10)(A)(ii)(XVII)

Family/Adult

Options for Coverage

31

Optional Targeted Low Income Children

Uninsured children who meet the definition of optional targeted low income children at 42 CFR 435.4, who have household income at or below a standard established by the State.

42 CFR 435.229 and 435.4; 1902(a)(10)(A)(ii)(XIV); 1905(u)(2)(B)

Family/Adult

Options for Coverage

32

Individuals Electing COBRA Continuation Coverage

Individuals choosing to continue COBRA benefits with income equal to or less than 100% of the FPL.

1902(a)(10)(F); 1902(u)(1)

Family/Adult

Options for Coverage

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.

CFR 435.218; 1902(hh); 1902(a)(10)(A)(ii)(XX)

Family/Adult

Options for Coverage

34

Certain Individuals Needing Treatment for Breast or Cervical Cancer

Individuals under the age of 65 who have been screened for breast or cervical cancer and need treatment.

42 CFR 435.213; 1902(a)(10)(A)(ii)(XVIII); 1902(aa)

Family/Adult

Options for Coverage

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.

42 CFR 435.214; 1902(a)(10)(A)(ii)(XXI)

Family/Adult

Options for Coverage

36

Individuals with Tuberculosis

Individuals infected with tuberculosis whose income does not exceed established standards, limited to tuberculosis-related services.

42 CFR 435.215; 1902(a)(10)(A)(ii)(XII); 1902(z)

Family/Adult

Options for Coverage

37

Aged, Blind or Disabled Individuals Eligible for but Not Receiving Cash Assistance

Individuals who meet the requirements of SSI or Optional State Supplement, but who do not receive cash.

42 CFR 435.210 & 230; 1902(a)(10)(A)(ii)(I);

ABD

Options for Coverage

38

Individuals Eligible for Cash Assistance 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.

42 CFR 435.211; 1902(a)(10)(A)(ii)(IV);

ABD

Options for Coverage

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.

42 CFR 435.217; 1902(a)(10)(A)(ii)(VI)

ABD

Options for Coverage

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).

42 CFR 435.232; 1902(a)(10)(A)(ii)(IV)

ABD

Options for Coverage

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 CFR 435.234; 1902(a)(10)(A)(ii)(XI)

ABD

Options for Coverage

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.

42 CFR 435.236; 1902(a)(10)(A)(ii)(V)

ABD

Options for Coverage

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.

1934

ABD

Options for Coverage

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.

1902(a)(10)(A)(ii)(VII); 1905(o)

ABD

Options for Coverage

45

Qualified Disabled Children under Age 19

Certain children under 19 living at home, who are disabled and would be eligible if they were living in a medical institution.

1902(e)(3)

ABD

Options for Coverage

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%).

1902(a)(10)(A)(ii)(X); 1902(m)(1)

ABD

Options for Coverage

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.

1902(a)(10)(A)(ii)(XIII)

ABD

Options for Coverage

48

Ticket to Work Basic Group

Individuals with earned income between ages 16 and 64 with a disability, with income and resources equal to or below a standard specified by the State.

1902(a)(10)(A)(ii)(XV)

ABD

Options for Coverage

49

Ticket to Work Medical Improvements Group

Individuals with earned income between ages 16 and 64 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.

1902(a)(10)(A)(ii)(XVI)

ABD

Options for Coverage

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).

1902(a)(10)(A)(ii)(XIX); 1902(cc)(1)

ABD

Options for Coverage

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.

1902(a)(10)(A)(ii)(XXII); 1915(i)

ABD

Options for Coverage

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 meet the eligibility requirements for a waiver approved for the State under 1915(c), (d) or (e), or 1115.

1902(a)(10)(A)(ii)(XXII); 1915(i)

ABD

Options for Coverage

MEDICAID MEDICALLY NEEDY

53

Medically Needy Pregnant Women

Women who are pregnant, who would qualify as categorically needy, except for income.

42 CFR 435.301(b)(1)(i) and (iv); 1902(a)(10)(C)(ii)(II)

Family/Adult

Medically Needy

54

Medically Needy Children under Age 18

Children under 18 who would qualify as categorically needy, except for income.

42 CFR 435.301(b)(1)(ii); 1902(a)(10)(C)(ii)(II)

Family/Adult

Medically Needy

55

Medically Needy Children Age 18 through 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.

42 CFR 435.308; 1902(a)(10)(C)(ii)(II)

Family/Adult

Medically Needy

56

Medically Needy Parents and Other Caretakers

Parents and other caretaker relatives of dependent children, eligible as categorically needy except for income.

42 CFR 435.310

Family/Adult

Medically Needy


Removed – Do Not Use






Removed – Do Not Use





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.

42 CFR 435.320, 435.322, 435.324,and 435.330; 1902(a)(10)(C)

ABD

Medically Needy

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.

42 CFR 435.340

ABD

Medically Needy

CHIP COVERAGE

61

Targeted Low-Income Children

Uninsured children under age 19 who do not have access to public employee coverage and whose household income is within standards established by the state.

42 CFR 457.310; 2102(b)(1)(B)(v)

Children

Optional

62

Deemed Newborn

Children born to targeted low-income pregnant women who are deemed eligible for CHIP or Medicaid for one year.

2112(e)

Children

Optional

63

Children Ineligible for Medicaid Due to Loss of Income Disregards

Children determined to be ineligible for Medicaid as a result of the elimination of income disregards under the MAGI income methodology.

42 CFR 457.340(d) Section 2101(f) of the ACA

Children

Mandatory

CHIP ADDITIONAL OPTIONS FOR COVERAGE

64

Coverage from Conception to Birth

Uninsured children from conception to birth who do not have access to public employee coverage and whose household income is within standards established by the state.

42 CFR 457.310 2102(b)(1)(B)(v)

Children

Option for Coverage

65

Children with Access to Public Employee Coverage

Uninsured children under age 19 having access to public employee coverage and whose household income is within standards established by the state.

2110(b)(2)(B) and (b)(6)

Children

Option for Coverage

66

Children Eligible for Dental Only Supplemental Coverage

Children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. Coverage is limited to dental services.

2110(b)(5)

Children

Option for Coverage

67

Targeted Low-Income Pregnant Women

Uninsured pregnant women who do not have access to public employee coverage and whose household income is within standards established by the state.

2112

Pregnant Women

Option for Coverage

68

Pregnant Women with Access to Public Employee Coverage

Uninsured pregnant women having access to public employee coverage and whose household income is within standards established by the state.

2110(b)(2)(B) and (b)(6)

Pregnant Women

Option for Coverage

1115 EXPANSION ELIGIBILITY GROUPS

69

Individuals with Mental Health Conditions (expansion group)

 Individuals with mental health conditions who do not qualify for Medicaid due to the severity or duration of their disability or due to other eligibility factors; and/or those who are otherwise eligible but require benefits or services that are not comparable to those provided to other Medicaid beneficiaries.

1115 expansion

 

 

70

Family Planning Participants (expansion group)

 Individuals of child bearing age who require family planning services and supplies and for which the state does not choose to, or cannot provide, optional eligibility coverage under the Individuals Eligible for Family Planning Services eligibility group (1902(a)(10)(A)(ii)(XXI)).

1115 expansion

 

 

71

Other expansion group

 Individuals who do not qualify for Medicaid or CHIP under a mandatory eligibility or coverage group and for whom the state chooses to provide eligibility and/or benefits in a manner not permitted by title XIX or XXI of the Social Security Act.

1115 expansion

 

 









Appendix G: ISO 639 Language Codes Reference

ISO 639-2 Code

Language

ISO 639-2 Code

Language

abk

Abkhazian

kru

Kurukh

ace

Achinese

kut

Kutenai

ach

Acoli

lad

Ladino

ada

Adangme

lah

Lahnda

ady

Adyghe; Adygei

lam

Lamba

aar

Afar

day

Land Dayak languages

afh

Afrihili

lao

Lao

afr

Afrikaans

lat

Latin

afa

Afro-Asiatic languages

lav

Latvian

ain

Ainu

lez

Lezghian

aka

Akan

lim

Limburgan; Limburger; Limburgish

akk

Akkadian

lin

Lingala

alb

Albanian

lit

Lithuanian

alb

Albanian

jbo

Lojban

ale

Aleut

nds

Low German; Low Saxon; German, Low; Saxon, Low

alg

Algonquian languages

dsb

Lower Sorbian

tut

Altaic languages

loz

Lozi

amh

Amharic

lub

Luba-Katanga

anp

Angika

lua

Luba-Lulua

apa

Apache languages

lui

Luiseno

ara

Arabic

smj

Lule Sami

arg

Aragonese

lun

Lunda

arp

Arapaho

luo

Luo (Kenya and Tanzania)

arw

Arawak

lus

Lushai

arm

Armenian

ltz

Luxembourgish; Letzeburgesch

rup

Aromanian; Arumanian; Macedo-Romanian

mac

Macedonian

art

Artificial languages

mad

Madurese

asm

Assamese

mag

Magahi

ast

Asturian; Bable; Leonese; Asturleonese

mai

Maithili

ath

Athapascan languages

mak

Makasar

aus

Australian languages

mlg

Malagasy

map

Austronesian languages

may

Malay

ava

Avaric

mal

Malayalam

ave

Avestan

mlt

Maltese

awa

Awadhi

mnc

Manchu

aym

Aymara

mdr

Mandar

aze

Azerbaijani

man

Mandingo

ban

Balinese

mni

Manipuri

bat

Baltic languages

mno

Manobo languages

bal

Baluchi

glv

Manx

bam

Bambara

mao

Maori

bai

Bamileke languages

arn

Mapudungun; Mapuche

bad

Banda languages

mar

Marathi

bnt

Bantu languages

chm

Mari

bas

Basa

mah

Marshallese

bak

Bashkir

mwr

Marwari

baq

Basque

mas

Masai

btk

Batak languages

myn

Mayan languages

bej

Beja; Bedawiyet

men

Mende

bel

Belarusian

mic

Mi'kmaq; Micmac

bem

Bemba

min

Minangkabau

ben

Bengali

mwl

Mirandese

ber

Berber languages

moh

Mohawk

bho

Bhojpuri

mdf

Moksha

bih

Bihari languages

lol

Mongo

bik

Bikol

mon

Mongolian

bin

Bini; Edo

mkh

Mon-Khmer languages

bis

Bislama

mos

Mossi

byn

Blin; Bilin

mul

Multiple languages

zbl

Blissymbols; Blissymbolics; Bliss

mun

Munda languages

nob

Bokmål, Norwegian; Norwegian Bokmål

nah

Nahuatl languages

bos

Bosnian

nau

Nauru

bra

Braj

nav

Navajo; Navaho

bre

Breton

nde

Ndebele, North; North Ndebele

bug

Buginese

nbl

Ndebele, South; South Ndebele

bul

Bulgarian

ndo

Ndonga

bua

Buriat

nap

Neapolitan

bur

Burmese

new

Nepal Bhasa; Newari

cad

Caddo

nep

Nepali

cat

Catalan; Valencian

nia

Nias

cau

Caucasian languages

nic

Niger-Kordofanian languages

ceb

Cebuano

ssa

Nilo-Saharan languages

cel

Celtic languages

niu

Niuean

cai

Central American Indian languages

nqo

N'Ko

khm

Central Khmer

nog

Nogai

chg

Chagatai

non

Norse, Old

cmc

Chamic languages

nai

North American Indian languages

cha

Chamorro

frr

Northern Frisian

che

Chechen

sme

Northern Sami

chr

Cherokee

nor

Norwegian

chy

Cheyenne

nno

Norwegian Nynorsk; Nynorsk, Norwegian

chb

Chibcha

nub

Nubian languages

nya

Chichewa; Chewa; Nyanja

nym

Nyamwezi

chi

Chinese

nyn

Nyankole

chn

Chinook jargon

nyo

Nyoro

chp

Chipewyan; Dene Suline

nzi

Nzima

cho

Choctaw

oci

Occitan (post 1500)

chu

Church Slavic; Old Slavonic; Church Slavonic; Old Bulgarian; Old Church Slavonic

arc

Official Aramaic (700-300 BCE); Imperial Aramaic (700-300 BCE)

chk

Chuukese

oji

Ojibwa

chv

Chuvash

ori

Oriya

nwc

Classical Newari; Old Newari; Classical Nepal Bhasa

orm

Oromo

syc

Classical Syriac

osa

Osage

cop

Coptic

oss

Ossetian; Ossetic

cor

Cornish

oto

Otomian languages

cos

Corsican

pal

Pahlavi

cre

Cree

pau

Palauan

mus

Creek

pli

Pali

crp

Creoles and pidgins

pam

Pampanga; Kapampangan

cpe

Creoles and pidgins, English based

pag

Pangasinan

cpf

Creoles and pidgins, French-based

pan

Panjabi; Punjabi

cpp

Creoles and pidgins, Portuguese-based

pap

Papiamento

crh

Crimean Tatar; Crimean Turkish

paa

Papuan languages

hrv

Croatian

nso

Pedi; Sepedi; Northern Sotho

cus

Cushitic languages

per

Persian

cze

Czech

peo

Persian, Old (ca.600-400 B.C.)

dak

Dakota

phi

Philippine languages

dan

Danish

phn

Phoenician

dar

Dargwa

pon

Pohnpeian

del

Delaware

pol

Polish

din

Dinka

por

Portuguese

div

Divehi; Dhivehi; Maldivian

pra

Prakrit languages

doi

Dogri

pro

Provençal, Old (to 1500);Occitan, Old (to 1500)

dgr

Dogrib

pus

Pushto; Pashto

dra

Dravidian languages

que

Quechua

dua

Duala

raj

Rajasthani

dum

Dutch, Middle (ca.1050-1350)

rap

Rapanui

dut

Dutch; Flemish

rar

Rarotongan; Cook Islands Maori

dyu

Dyula

roa

Romance languages

dzo

Dzongkha

rum

Romanian; Moldavian; Moldovan

frs

Eastern Frisian

roh

Romansh

efi

Efik

rom

Romany

egy

Egyptian (Ancient)

run

Rundi

eka

Ekajuk

rus

Russian

elx

Elamite

sal

Salishan languages

eng

English

sam

Samaritan Aramaic

enm

English, Middle (1100-1500)

smi

Sami languages

ang

English, Old (ca.450-1100)

smo

Samoan

myv

Erzya

sad

Sandawe

epo

Esperanto

sag

Sango

est

Estonian

san

Sanskrit

ewe

Ewe

sat

Santali

ewo

Ewondo

srd

Sardinian

fan

Fang

sas

Sasak

fat

Fanti

sco

Scots

fao

Faroese

sel

Selkup

fij

Fijian

sem

Semitic languages

fil

Filipino; Pilipino

srp

Serbian

fin

Finnish

srr

Serer

fiu

Finno-Ugrian languages

shn

Shan

fon

Fon

sna

Shona

fre

French

iii

Sichuan Yi; Nuosu

frm

French, Middle (ca.1400-1600)

scn

Sicilian

fro

French, Old (842-ca.1400)

sid

Sidamo

fur

Friulian

sgn

Sign Languages

ful

Fulah

bla

Siksika

gaa

Ga

snd

Sindhi

gla

Gaelic; Scottish Gaelic

sin

Sinhala; Sinhalese

car

Galibi Carib

sit

Sino-Tibetan languages

glg

Galician

sio

Siouan languages

lug

Ganda

sms

Skolt Sami

gay

Gayo

den

Slave (Athapascan)

gba

Gbaya

sla

Slavic languages

gez

Geez

slo

Slovak

geo

Georgian

slv

Slovenian

ger

German

sog

Sogdian

gmh

German, Middle High (ca.1050-1500)

som

Somali

goh

German, Old High (ca.750-1050)

son

Songhai languages

gem

Germanic languages

snk

Soninke

gil

Gilbertese

wen

Sorbian languages

gon

Gondi

sot

Sotho, Southern

gor

Gorontalo

sai

South American Indian languages

got

Gothic

alt

Southern Altai

grb

Grebo

sma

Southern Sami

grc

Greek, Ancient (to 1453)

spa

Spanish; Castilian

gre

Greek, Modern (1453-)

srn

Sranan Tongo

grn

Guarani

suk

Sukuma

guj

Gujarati

sux

Sumerian

gwi

Gwich'in

sun

Sundanese

hai

Haida

sus

Susu

hat

Haitian; Haitian Creole

swa

Swahili

hau

Hausa

ssw

Swati

haw

Hawaiian

swe

Swedish

heb

Hebrew

gsw

Swiss German; Alemannic; Alsatian

her

Herero

syr

Syriac

hil

Hiligaynon

tgl

Tagalog

him

Himachali languages; Western Pahari languages

tah

Tahitian

hin

Hindi

tai

Tai languages

hmo

Hiri Motu

tgk

Tajik

hit

Hittite

tmh

Tamashek

hmn

Hmong; Mong

tam

Tamil

hun

Hungarian

tat

Tatar

hup

Hupa

tel

Telugu

iba

Iban

ter

Tereno

ice

Icelandic

tet

Tetum

ido

Ido

tha

Thai

ibo

Igbo

tib

Tibetan

ijo

Ijo languages

tig

Tigre

ilo

Iloko

tir

Tigrinya

smn

Inari Sami

tem

Timne

inc

Indic languages

tiv

Tiv

ine

Indo-European languages

tli

Tlingit

ind

Indonesian

tpi

Tok Pisin

inh

Ingush

tkl

Tokelau

ina

Interlingua (International Auxiliary Language Association)

tog

Tonga (Nyasa)

ile

Interlingue; Occidental

ton

Tonga (Tonga Islands)

iku

Inuktitut

tsi

Tsimshian

ipk

Inupiaq

tso

Tsonga

ira

Iranian languages

tsn

Tswana

gle

Irish

tum

Tumbuka

mga

Irish, Middle (900-1200)

tup

Tupi languages

sga

Irish, Old (to 900)

tur

Turkish

iro

Iroquoian languages

ota

Turkish, Ottoman (1500-1928)

ita

Italian

tuk

Turkmen

jpn

Japanese

tvl

Tuvalu

jav

Javanese

tyv

Tuvinian

jrb

Judeo-Arabic

twi

Twi

jpr

Judeo-Persian

udm

Udmurt

kbd

Kabardian

uga

Ugaritic

kab

Kabyle

uig

Uighur; Uyghur

kac

Kachin; Jingpho

ukr

Ukrainian

kal

Kalaallisut; Greenlandic

umb

Umbundu

xal

Kalmyk; Oirat

mis

Uncoded languages

kam

Kamba

und

Undetermined

kan

Kannada

hsb

Upper Sorbian

kau

Kanuri

urd

Urdu

krc

Karachay-Balkar

uzb

Uzbek

kaa

Kara-Kalpak

vai

Vai

krl

Karelian

ven

Venda

kar

Karen languages

vie

Vietnamese

kas

Kashmiri

vol

Volapük

csb

Kashubian

vot

Votic

kaw

Kawi

wak

Wakashan languages

kaz

Kazakh

wln

Walloon

kha

Khasi

war

Waray

khi

Khoisan languages

was

Washo

kho

Khotanese; Sakan

wel

Welsh

kik

Kikuyu; Gikuyu

fry

Western Frisian

kmb

Kimbundu

wal

Wolaitta; Wolaytta

kin

Kinyarwanda

wol

Wolof

kir

Kirghiz; Kyrgyz

xho

Xhosa

tlh

Klingon; tlhIngan-Hol

sah

Yakut

kom

Komi

yao

Yao

kon

Kongo

yap

Yapese

kok

Konkani

yid

Yiddish

kor

Korean

yor

Yoruba

kos

Kosraean

ypk

Yupik languages

kpe

Kpelle

znd

Zande languages

kro

Kru languages

zap

Zapotec

kua

Kuanyama; Kwanyama

zza

Zaza; Dimili; Dimli; Kirdki; Kirmanjki; Zazaki

kum

Kumyk

zen

Zenaga

kur

Kurdish

zha

Zhuang; Chuang



zul

Zulu



zun

Zuni





Appendix H: Benefit Types

Code Value

Benefit

Short Description

Category

Type of Care

Long Term Care*

Citations (Act and 42 CFR)

 

Mandatory Benefits for Categorically Needy (Mandatory and Options for Coverage) Individuals and Optional Benefits for Medically Needy Individuals

001

Inpatient Hospital Services

Services furnished in a hospital or institution (licensed or formally approved as a hospital), for the care and treatment of inpatients with disorders other than mental health disease.

Mandatory

Institutional

No

1905(a)(1), 440.10, 440.189(g)

002

Outpatient Hospital Services

Preventive, diagnostic, therapeutic, rehabilitative, or palliative services furnished to outpatients by a hospital or institution (licensed or formally approved as a hospital).

Mandatory

Ambulatory

No

1905(a)(2)(A), 440.20(a)

003

Rural Health Clinics

Services and supplies provided by a physician within the scope of his/her practice, a physician assistant (if not prohibited by state law), nurse practitioner (if not prohibited by state law) nurse midwife, or other specialized nurse practitioners, intermittent visiting nurse care and related medical supplies (other than drugs and biologicals), and other ambulatory services when furnished in a certified rural health clinic or away from the clinic if an agreement between the physician and clinic for payment of services by the clinic exists.

Mandatory

Ambulatory

No

1905(a)(2)(B), 440.20(b) and (c), 1910(a)

004

Federally Qualified Health Centers

Services and related supplies provided by a physician within the scope of his/her practice, physician assistants, nurse practitioners, nurse midwives, clinical psychologists, clinical social workers, and other ambulatory services when furnished in a federally qualified health center.

Mandatory

Ambulatory

No

1905(a)(2)(C)

005

Other Laboratory and X-Ray Services

Technical and radiological services ordered and provided by or under direction of a physician or other licensed practitioner in an office or similar facility other than a clinic or hospital outpatient department and furnished by an approved laboratory.

Mandatory

Ambulatory

No

1905(a)(3), 440.30

006

Nursing Facility Services for Individuals Age 21 and Older

Services (other than services in an institution for mental health conditions), furnished to individuals age 21 and older, which are needed on a daily basis and required to be provided in an inpatient basis provided by a Medicaid-approved facility and ordered by and provided under the direction of a physician.

Mandatory

Institutional

Yes

1905(a)(4)(A), 440.40(a)

007

Early and Periodic Screening, Diagnostic and Treatment Services

Screening and diagnostic services to determine physical or mental health condition; health care treatment and other measures to correct or ameliorate any chronic conditions discovered in recipients under age 21.

Mandatory

Both

No

1905(a)(4)(B), 1902(a)(43), 1905(r)

008

Family Planning Services and Supplies

Family planning services and supplies furnished (directly or under arrangements with others) to individuals of child-bearing age (including minors who can be considered to be sexually active) who desire such services and supplies.

Mandatory

Ambulatory

No

1905(a)(4)(C), 441 Subpart F

009

Cessation of Tobacco Use by Pregnant Women

Counseling and pharmacotherapy services for cessation of tobacco use by pregnant women.

Mandatory

Ambulatory

No

1905(a)(4)(D)

010

Physician Services

Services furnished by a state-licensed physician within his or her scope of practice of medicine or osteopathy.

Mandatory

Ambulatory

No

1905(a)(5)(A), 440.50(a)

011

Medical and Surgical Services Furnished by a Dentist

Medical and surgical services furnished by a doctor of dental medicine or dental surgery, or if permitted by state law, by a physician.

Mandatory

Ambulatory

No

1905(a)(5)(B), 440.50(b)

012

Nurse Midwife Services

Services furnished by a licensed nurse midwife within the scope of practice authorized by State law or regulation; Inpatient or outpatient hospital services or clinic services furnished by a licensed nurse midwife under the supervision of, or associated with a physician or other health care provider.

Mandatory

Ambulatory

No

1905(a)(17), 440.165

013

Certified Pediatric or Family Nurse Practitioner Services

Services furnished by a certified pediatric nurse practitioner with a practice limited to providing primary health care to individuals under age 21; or a certified family nurse practitioner with a practice limited to providing primary health care to individuals and families.

Mandatory

Ambulatory

No

1905(a)(21), 440.166

014

Free Standing Birth Center Services

Services furnished to an individual at a freestanding birth center, which include prenatal labor and delivery, or postpartum care and other ambulatory services related to the health and safety of the individual.

Mandatory

Institutional

No

1905(a)(28)

015

Home Health Services - Intermittent and Part-time Nursing Services Provided by a Home Health Agency

Nursing service that is provided on a part-time or intermittent basis by a home health agency or in the absence of an agency in the area, by a registered nurse.

Mandatory

Ambulatory

Yes

1905(a)(7), 440.70(b)(1), 441.15

016

Home Health Services - Home Health Aide Services Provided by a Home Health Agency

Home health aide services provided by a home health agency.

Mandatory

Ambulatory

Yes

1905(a)(7), 440.70(b)(2), 441.15

017

Home Health Services - Medical Supplies, Equipment and Appliances Suitable for Use in the Home

Services include medical supplies, equipment and appliances suitable for use in the home.

Mandatory

Ambulatory

Yes

1905(a)(7), 440.70(b)(3), 441.15

 

Optional Benefits for Categorically Needy (Mandatory and Options for Coverage) and Medically Needy Individuals

018

Medical Care and Any Type of Remedial Care Recognized Under State Law - Podiatrist Services

Medical or remedial care or services provided by licensed podiatrists within the scope of practice as defined under state law.

Optional

Ambulatory

No

1905(a)(6), 440.60

019

Medical Care and Any Type of Remedial Care Recognized Under State Law - Optometrist Services

Medical or remedial care or services provided by licensed optometrists within the scope of practice as defined under state law

Optional

Ambulatory

No

1905(a)(6), 440.60

020

Medical Care and Any Type of Remedial Care Recognized Under State Law - Chiropractors' Services

Services provided by licensed chiropractors consisting of treatment by means of manual manipulation of the spine within the scope authorized by the state to perform.

Optional

Ambulatory

No

1905(a)(6), 440.60

021

Medical Care and Any Type of Remedial Care Recognized Under State Law - Other Licensed Practitioner Services

Medical or any other remedial care or services provided by a licensed practitioner within the scope of his/her practice as defined by state law.

Optional

Ambulatory

No

1905(a)(6), 440.60

022

Home Health Services - Physical Therapy, Occupational Therapy, Speech Pathology, Audiology Provided by a Home Health Agency

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 medical rehabilitation services.

Optional

Ambulatory

Yes

1905(a)(7), 440.70(b)(4), 441.15

023

Private Duty Nursing Services

Nursing services, provided by RNs or LPNs, in a home, hospital, or skilled nursing facility, to recipients who require more individual and continuous care than is available from a visiting nurse, or routinely provided by hospital or skilled nursing facility staff.

Optional

Ambulatory

Yes

1905(a)(8), 440.80

024

Clinic Services

Preventive, diagnostic, therapeutic, rehabilitative or palliative services furnished by a facility that is not part of a hospital, but is organized and operated to provide medical care; services provided at the clinic or outside the clinic under the direction of a physician or dentist.

Optional

Ambulatory

No

1905(a)(9), 440.90

025

Dental Services

Diagnostic, preventive, or corrective procedures provided by or under the supervision of a licensed dentist; treatment of the teeth and associated structures of the oral cavity; treatment of disease, injury, or impairment that my affect general health of recipient.

Optional

Ambulatory

No

1905(a)(10), 440.100

026

Physical Therapy and Related Services- Physical Therapy

Services prescribed by a physician or other licensed practitioner of the healing arts, and provided to a recipient by or under the direction of a qualified physical therapist; includes supplies and equipment.

Optional

Ambulatory

Yes

1905(a)(11), 440.110(a)

027

Physical Therapy and Related Services- Occupational Therapy

Services provided by a qualified occupational therapist, which have been prescribed by a physician or practitioner of the healing arts; includes supplies and equipment.

Optional

Ambulatory

Yes

1905(a)(11), 440.110(b)

028

Physical Therapy and Related Services - Services for Individuals with Speech, Hearing and Language Disorders

Diagnostic, screening, preventive or corrective services for individuals with speech, hearing and language disorders; provided by or under the direction of a certified speech pathologist or audiologist or other licensed practitioner of the healing arts; includes supplies and equipment.

Optional

Ambulatory

Yes

1905(a)(11), 440.110(c )

029

Prescribed Drugs, Dentures, and Prosthetic Devices; and Eyeglasses - Prescribed Drugs

Single or compound substances or mixture of substances prescribed by a physician or licensed practitioner, and dispensed by a licensed pharmacist or authorized practitioner, for the cure, mitigation, or prevention of disease or maintenance of health.

Optional

Ambulatory

No

1905(a)(12), 440.120(a)

030

Prescribed Drugs, Dentures, and Prosthetic Devices; and Eyeglasses - Dentures

Artificial structures made by or under the direction of a dentist to replace a full or partial set of teeth.

Optional

Ambulatory

No

1905(a)(12), 440.120(b)

031

Prescribed Drugs, Dentures, and Prosthetic Devices; and Eyeglasses - Prosthetic Devices

Replacement, corrective or supportive devices prescribed by a physician or licensed practitioner, to artificially replace a missing portion of the body, prevent or correct physical deformity or malfunction, or to support a weak or deformed portion of the body.

Optional

Ambulatory

No

1905(a)(12), 440.120(c )

032

Prescribed Drugs, Dentures, and Prosthetic Devices; and Eyeglasses - Eyeglasses

Lenses, including frames and other aids to vision, prescribed by a physician skilled in eye disease, or an optometrist.

Optional

Ambulatory

No

1905(a)(12), 440.120(d)

033

Other Diagnostic, Screening, Preventive, and Rehabilitative Services - Diagnostic Services

Medical procedures or supplies recommended by a physician or licensed practitioner to enable him/her to identify the existence, nature or extent of illness, injury or other health deviation in a recipient.

Optional

Ambulatory

No

1905(a)(13), 440.130(a)

034

Other Diagnostic, Screening, Preventive, and Rehabilitative Services - Screening Services

Use of standardized tests given to a designated population, to detect the existence of one or more particular diseases or health deviations or to identify for more definitive studies individuals suspected of having certain diseases.

Optional

Ambulatory

No

1905(a)(13), 440.130(b)

035

Other Diagnostic, Screening, Preventive, and Rehabilitative Services - Preventive Services

Services provided by a physician or other licensed practitioner to prevent disease, disability or other health conditions or their progression, to prolong life and to promote physical and mental health efficiency.

Optional

Ambulatory

No

1905(a)(13), 440.130(c )

036

Other Diagnostic, Screening, Preventive, and Rehabilitative Services - Rehabilitative Services

Medical or remedial services recommended by a physician or other licensed practitioner for maximum reduction of physical or mental health condition, and restoration of a recipient to his/her best possible functional level.

Optional

Ambulatory

Yes

1905(a)(13), 440.130(d)

037

Services for Individuals Age 65 and Over in IMDs - Inpatient Hospital Services

Services for the care and treatment of recipients, age 65 and older, in an institution for mental health conditions, provided under the direction of a physician.

Optional

Institutional

Yes

1905(a)(14), 440.140(a)

038

Services for Individuals Age 65 and Over in IMDs - Nursing Facility Services

Nursing services needed on a daily basis and required to be provided on an inpatient basis to individuals age 65 and older in an institution for mental health conditions.

Optional

Institutional

Yes

1905(a)(14), 440.140(b)

039

Intermediate Care Facility Services for Individuals with Intellectual Disabilities (ICF-IID)

Items and health rehabilitative services provided to persons with intellectual disabilities or related conditions, receiving active treatment in a licensed ICF/IID.

Optional

Institutional

Yes

1905(a)(15), 440.150

040

Inpatient Psychiatric Services for Individuals Under 21

Inpatient psychiatric services provided to individuals under age 21, under the direction of a physician, furnished in an approved and accredited psychiatric hospital or facility.

Optional

Institutional

Yes

1905(a)(16), 440.160

041

Hospice Care Services

Items and services provided to a terminally ill individual, which includes nursing care, physical or occupational therapy, medical social services, homemaker services, medical supplies and appliances, physician services, short-term inpatient care and counseling.

Optional

Both

Yes

1905(a)(18)

042

Case Management and TB-Related Services - Case Management and Targeted Case Management Services

Services to assist eligible individuals who reside in a community setting or are transitioning to a community setting, in gaining access to medical, social, educational, and other services. As specified in a state’s plan, may be offered to individuals within targeted groups.

Optional

Ambulatory

Yes

1905(a)(19), 440.169, 1915(g)

043

Case Management Services and TB-Related Services -Special TB Related Services

Services for the treatment of infection with tuberculosis consisting of prescribed drugs, physicians’ services, laboratory and x-ray services (including services to confirm the presence of infection), clinic services and federally-qualified health center services, case management services, and services (other than room and board) designed to encourage completion of regimens of prescribed drugs by outpatients, including services to observe directly the intake of prescribed drugs.

Optional

Ambulatory

No

1905(a)(19)

044

Respiratory Care Services

Services provided in home, under the direction of a physician, by a respiratory therapist or other health care professional trained in respiratory therapy, to an individual who is medically dependent on a ventilator for life support for 6 hours or more per day, has been dependent on the ventilator for at least 30 consecutive days as an inpatient in a hospital, NF or ICF/IID, has adequate social support, and wishes to be cared for at home.

Optional

Ambulatory

No

1905(a)(20), 1902(e)(9)(A)-(C ), 440.185

045

Personal Care Services

Services, furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, or intermediate facility for individuals with intellectual and or developmental disabilities, or institution for mental health conditions, that are authorized by a physician in accordance with a plan of treatment, and provided by an individual qualified to provide such services, who is not a legally responsible relative.

Optional

Ambulatory

Yes

1905(a)(24), 440.167

046

Primary Care Case Management Services (Integrated Care Model)

Case management related services which include location, coordination, and monitoring of primary health care services and provider under a contract between the State and either a PCCM who is a physician, or at the State’s option, a physician assistant, nurse practitioner, certified nurse midwife, physician group practice, or an entity that employs or arranges with physicians to furnish services.

Optional

Ambulatory

No

1905(a)(25), 440.168

047

Special Sickle-Cell Anemia-Related Services

Primary and secondary medical strategies and treatment and services for individuals who have Sickle Cell Disease.

Optional

Ambulatory

No

1905(a)(27)

048

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

Expenses for transportation and other related travel expenses determined to be necessary by the agency to secure medical examinations and treatment for a beneficiary.

Optional, but states are required to assure that transportation is available to and from Medicaid services, either as a State Plan benefit, an administrative activity or under a waiver

Ambulatory

No

1905(a)(29), 440.170(a)

049

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

Non-medical services and items, furnished in an institution that is defined in the Internal Revenue Code and is exempt from taxes, to patients who choose to rely solely upon a religious method of healing and for whom the acceptance of medical health services would be inconsistent with their religious beliefs.

Optional

Institutional

Yes

1905(a)(29), 440.170(b) and (c )

050

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

Services (other than services in an Institution for mental health conditions), furnished to individuals under the age of 21, which are needed on a daily basis and required to be provided in an inpatient basis provided by a Medicaid-approved facility and ordered by and provided under the direction of a physician.

Optional

Institutional

Yes

1905(a)(29), 440.170(d)

051

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

Services that are necessary to prevent death or serious impairment of health of a recipient, and that the threat to life or health necessitates that use of the most accessible hospital available that is equipped to furnish the services, with no regard to conditions of participation under Medicare or definitions of inpatient or outpatient hospital services.

Optional

Ambulatory

No

1905(a)(29), 440.170(e)

052

Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary - Critical Access Hospitals

Services that are furnished by a Medicare participating Critical Access Hospital (CAH) provider and are of a type that would be paid for by Medicare when provided to a Medicare recipient, other than nursing facility services by a CAH with a swing-bed approval.

Optional

Institutional

No

1905(a)(29), 440.170(g)

053

Extended Services for Pregnant Women - Additional Services for Any Other Medical Conditions That May Complicate Pregnancy

Extended services for pregnant women - Additional Services for any other medical conditions that may complicate pregnancy, except 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. (These services will fall into valid value # 71.)

Optional

Ambulatory

No

1902(a)(10)(end)(V)

054

Community First Choice

Home and community-based attendant services and supports to assist eligible beneficiaries in accomplishing activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision or cueing.

Optional

Ambulatory

No

1915(k)

055

Health Homes

Comprehensive and timely high-quality services that are provided by a designated provider, a team of health care professionals operating with such a provider, or a health team. Services include care management, care coordination and promotion, comprehensive transitional care, patient and family support, referral to community and social support services, and use of information technology to link services.

Optional

Ambulatory

No

1945

 

Special Benefit Provisions

056

Limited Pregnancy-Related Services for Pregnant Women with Income Above the Applicable Income Limit

Potentially limited services for pregnant women with income above a certain limit to pregnancy-related services that are necessary for the health of the pregnant woman and fetus, or have become necessary as a result of the woman having been pregnant, including, but not limited to prenatal care, delivery, postpartum care, and family planning services.

 

 

No

1902(a)(10)(end)(VII), 440.210(a)(2), 440.250(p)

057

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

Ambulatory prenatal care services provided to an eligible pregnant woman during the PE period, which begins on the date a pregnant woman is determined presumptively eligible by a Medicaid qualified provider based on preliminary information, and ends on the day on which a full determination of eligibility is made or at the end of the month following the month in which the PE determination was made if the woman fails to file an application for full benefits.

 

 

No

1920, 1902(a)(47)

058

Benefits for Families Receiving Transitional Medical Assistance

Benefits provided to families who would have lost eligibility because of hours of, or income from employment of the caretaker relative. Benefits may be limited or provided through alternative methods during the second six months of the 12 month period of extended benefits.

 

 

 

1925, 1902(a)(52)

059

Standards for Coverage of Transplant Services

Standards which provide that similarly situated individuals are treated alike and any restriction, on the facilities or practitioners which may provide such procedures, is consistent with accessibility to high quality care.

 

 

 

1903(i)(1), 441.35

060

School-Based Services Payment Methodologies

Provision of benefits in a school-based setting or arranged by a school to a child with a disability even if such services are included in the child's individualized education program (IEP), and to an infant or toddler with a disability even if such services are included in the child's individualized family service plan (IFSP).

 

 

 

1903(c )

061

Indian Health Services and Tribal Health Facilities

Allows for reimbursement of state plan covered services when provided by a facility of the Indian Health Service, including a hospital, nursing facility or any other type of facility which provides covered services under the state plan.

 

 

 

1911, 431.110(b)

062

Methods and Standards to Assure High Quality Care

The plan must include a description of methods and standards used to assure that services are of high quality and that the care and services are available under the plan at least to the extent that such care and services are available to the general populations in the geographic area.

 

 

 

1902(a)(30)(A), 440.260

 

Coordination of Medicaid with Medicare and Other Insurance

063

Medicare Premium Payments

Provisions related to payment of Medicare A, B and C premiums for qualifying Medicaid beneficiaries.

 

 

 

1902(a)(10(E ), 1905(p), 1905(s), 1933, 431.625

064

Medicare Coinsurance and Deductibles

Provisions for Medicaid payment of Medicare coinsurance and deductibles for individuals dually eligible for Medicare and Medicaid.

 

 

 

1902(a)(10(E ), 1902(n), 1905(p)(3) and (4)

065

Other Medical Insurance Premium Payments

Payment of insurance premiums, if cost-effective, for eligible individuals; payment of COBRA premiums; and requirement of enrollment in an employer-sponsored insurance with payment of premiums, if cost-effective.

 

 

 

1906, 1906A, 1902(a)(10)(F), 1902(u)(1)

 

Special Benefit Programs

066

Programs for Distribution of Pediatric Vaccines

The establishment of a pediatric vaccine distribution program, which provides eligible children with qualified pediatric vaccines.

Mandatory

 

 

1928

 

Home and Community-Based Services

067

Laboratory and x-ray services

 

 

 

 

 

068

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

 

 

 

 

 

069

Private duty nursing services

 

 

 

 

 

070

Physical Therapy and Related Services - Audiology services

 

 

 

 

 

071

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.

 

 

 

 

 

072

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

 

 

 

 

 

073

Emergency services for certain legalized aliens and undocumented aliens

An emergency medical condition is a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

 

 

 

 

074

Licensed or Otherwise State-Approved Free-Standing Birthing Center and other ambulatory services that are offered by a freestanding birth center

 

 

 

 

 

075

Homemaker

 

 

 

 

 

076

Home Health Aide

 

 

 

 

 

077

Adult Day Health services

 

 

 

 

 

078

Habilitation

 

 

 

 

 

079

Habilitation: Residential Habilitation

 

 

 

 

 

080

Habilitation: Supported Employment

 

 

 

 

 

081

Habilitation: Education (non IDEA available)

 

 

 

 

 

082

Habilitation: Day Habilitation

 

 

 

 

 

083

Habilitation: Pre-Vocational

 

 

 

 

 

084

Habilitation: Other Habilitative Services

 

 

 

 

 

085

Respite

 

 

 

 

 

086

Day Treatment (mental health service)

 

 

 

 

 

087

Psychosocial rehabilitation

 

 

 

 

 

088

Environmental Modifications (Home Accessibility Adaptations)

 

 

 

 

 

089

Vehicle Modifications

 

 

 

 

 

090

Non-Medical Transportation

 

 

 

 

 

091

Special Medical Equipment (minor assistive Devices)

 

 

 

 

 

092

Home Delivered meals

 

 

 

 

 

093

Assistive Technology (i.e., communication devices)

 

 

 

 

 

094

Personal Emergency Response (PERS)

 

 

 

 

 

095

Nursing Services

 

 

 

 

 

096

Community Transition Services

 

 

 

 

 

097

Adult Foster Care

 

 

 

 

 

098

Day Supports (non-habilitative)

 

 

 

 

 

099

Supported Employment

 

 

 

 

 

100

Supported Living Arrangements

 

 

 

 

 

101

Supports for Consumer Direction (Supports Facilitation)

 

 

 

 

 

102

Participant Directed Goods and Services

 

 

 

 

 

103

Senior Companion (Adult Companion Services)

 

 

 

 

 

104

Assisted Living

 

 

 

 

 

 

Other

105

Program for All-inclusive Care for the Elderly (PACE) Services

 

 

 

 

 

106

Self-directed Personal Assistance Services under 1915(j)

 

 

 

 

 





Appendix I: MBES CBES Category of Service Line Definitions for the 64.9 Base Form

Line

Line - Form Display

Line - Definition

1A

Inpatient Hospital - Reg. Payments

1A. - Inpatient Hospital Services.-- Regular Payments.--Other than services in an institution for mental health conditions. (See 42 CFR 440.10). These are services that:

  • Are ordinarily furnished in a hospital for the care and treatment of inpatients;

  • Are furnished under the direction of a physician or dentist (except in the case of nurse-midwife services under 42 CFR 440.165); and

  • Are furnished in an institution that:

  • Is maintained primarily for the care and treatment of patients with disorders other than mental health conditions;

  • Is licensed and 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 under 42 CFR 440.165); and

  • Has, in effect, a utilization review plan (that meets the requirements under 42 CFR 482.30 applicable to all Medicaid patients, unless a waiver has been granted by DHHS.

NOTE: Inpatient hospital services do not include NF 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.

1B

Inpatient Hospital - DSH

1.B. Inpatient Hospital Services -- DSH Adjustment Payment. - Other than services in an institution for mental health conditions. DSH payments are for the express purpose of assisting hospitals that serve a disproportionate share of low-income patients with special needs and are made in accordance with section 1923 of the Act.

Report the total payments that were determined to be disproportionate share payments to the hospital by entering the amounts on the pop-up feeder form which in turn will pre-fill the Form CMS-64.9D as well as the appropriate lines on the Forms CMS-64.9, CMS-64.9P, CMS-64.21, CMS-64.21P, CMS-6421U or CMS-64.21UPs.

1C

Inpatient Hospital - Sup. Payments

1C. - Inpatient Hospital Services.- Supplemental Payments.--Other than services in an institution for mental health conditions. (Refer to the definition on Line 1A above). These are payments made in addition to the standard fee schedule or other standard payment for those services. These payments are separate and apart from regular payments and are based on their own payment methodology. Payments may be made to all providers or targeted to specific groups or classes of providers. Groups may be defined by ownership type (state, county or private) and/or by the other characteristics, e.g., caseload, services or costs. The combined standard payment and supplemental payment cannot exceed the upper payment limit described in 42 CFR 447.272. Address supplemental payments for inpatient hospitals associated with (1) state government operated facilities, (2) non-state government operated facilities, and (3) privately operated facilities by entering payments on the pop-up feeder form.

1D

Inpatient Hospital - GME Payments

1D. - Inpatient Hospital Services.—Graduate Medical Education (GME) Payments.-- GME payments include supplemental payments for direct medical education (DME) (i.e. costs of training physicians such as resident and teaching physician salaries/benefits, overhead and other costs directly related to the program) and indirect medical education (IME) costs hospitals incur for operating teaching programs. Report all supplemental payments for DME and IME that are provided for in the State plan.

2A

Mental Health Facility Services - Reg. Payments

2.A. Mental Health Facility Services - Report Institution for Mental Disease (IMD) (or mental health conditions) services for individuals age 65 or older and/or under age 21 (See 42 CFR 440.140 and 440.160.).

Report Other Mental Services which are not provided in an inpatient setting in the Other Appropriate Service categories, e.g., Physician Services, Clinic Services.

1. Mental Health Hospital Services for the Aged.--Refers to those inpatient hospital services provided under the direction of a physician for the care and treatment of recipients in an institution for mental health conditions that meets the Conditions of Participation under 42 CFR Part 482. Institution for mental health conditions means an institution that is primarily engaged in providing diagnosis, treatment, or care of individuals with mental health conditions, including medical care, nursing care, and related services. (See 42 CFR 440.140(a)(2).)

2. NF Services for the Aged.--Means those NF services (as defined at 42 CFR 440.40) and those ICF services (as defined at 42 CFR 483, Subpart B) provided in an institution for mental health conditions to recipients determined to be in need of such services. (See 42 CFR 440.140.)

3. Inpatient Psychiatric Facility Services for Individuals Age 21 and Under. (See 42 CFR 441.151) --Means those services that:

  • Are provided under the direction of a physician;

  • Are provided in a facility or program accredited by the Joint Commission on the Accreditation of Health Care Organizations; and

  • Meet the requirements set forth at Subpart D of Part 441 (Inpatient Psychiatric Services for Individuals Age 21 and under in Psychiatric Facilities or Programs).

2B

Mental Health Facility - DSH

2.B. Mental Health Facility Services -- DSH Adjustment Payments.- (See 42 CFR 440.140 and 440.160). DSH payments are for the express purpose of assisting hospitals that serve a disproportionate share of low-income patients with special needs and are made in accordance with section 1923 of the Act.

Report the total payments that were determined to be disproportionate share payments to the hospital by entering the amounts on the pop-up feeder form which in turn will pre-fill the Form CMS-64.9D as well as the appropriate lines on the Forms CMS-64.9, CMS-64.9P, CMS-64.21, CMS-64.21P, CMS-6421U or CMS-64.21UPs.

3A

Nursing Facility Services - Reg. Payments

3A. - Nursing Facility Services.--Regular Payments.-- (Other than services in an institution for mental health conditions). (See 42 CFR 483.5 and 440.155).

These are services provided by an institution (or a distinct part of an institution) which:

  • 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 health conditions; and

  • 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 Residences Rights, and

  • Requirements relating to Administration and Other Matters.

3B

Nursing Facility Services - Sup. Payments

3B. - Nursing Facility Services - Supplemental Payments.-- (Other than services in an institution for mental health conditions). (Refer to the definition on Line 3A above). These are payments made in addition to the standard fee schedule or other standard payment for those services. These payments are separate and apart from regular payments and are based on their own payment methodology. Payments may be made to all providers or targeted to specific groups or classes of providers. Groups may be defined by ownership type (state, county or private) and/or by the other characteristics, e.g., caseload, services or costs. The combined standard payment and supplemental payment cannot exceed the upper payment limit described in 42 CFR 447.272.

Address supplemental payments for nursing facility services associated with

  1. state government operated facilities,

  2. non-state government operated facilities, and

  3. privately operated facilities by entering payments on the pop-up feeder form.

4A

Intermediate Care Facility Services – Individuals with Intellectual Disabilities: Public Providers

4A Intermediate Care Facility Services - Public Providers – Individuals with Intellectual Disabilities (ICF/IID) (See 42 CFR 440.150).

These include services provided in an institution for individuals with intellectual disabilities or persons with related conditions if:

  • The primary purpose of the institution is to provide health or rehabilitative services to such individuals;

  • The institution meets the standards in 42 CFR 442, Subpart C (Intermediate Care Facility Requirements; All Facilities); and

  • Individuals with intellectual disabilities recipient for whom payment is requested is receiving active treatment as defined in 42 CFR 435.1009.

NOTE: Line 4 is divided into sections for public providers (Line 4.A.) and private providers (Line 4.B.). Public providers are owned or operated by a State, county, city or other local governmental agency or instrumentality. Increasing adjustments related to private providers are considered current expenditures for the quarter in which the expenditure was made and are matched at the FMAP rate for that quarter. Increasing adjustments related to public providers are considered adjustments to prior period claims and are matched using the FMAP rate in effect at the earlier of the time the expenditure was paid or recorded by any State agency. (See 45 CFR Part 95 and §2560.)

4B

Intermediate Care Facility Services - Individuals with Intellectual Disabilities: Private Providers

4B --Intermediate Care Facility Services - Private Providers - Individuals with Intellectual Disabilities (ICF/IID). (See 42 CFR 440.150).

These include services provided in an institution for individuals with intellectual disabilities or persons with related conditions if:

  • The primary purpose of the institution is to provide health or rehabilitative services to such individuals;

  • The institution meets the standards in 42 CFR 442, Subpart C (Intermediate Care Facility Requirements; All Facilities); and

  • Individuals with intellectual disabilities recipient for whom payment is requested is receiving active treatment as defined in 42 CFR 435.1009.

NOTE: Line 4 is divided into sections for public providers (Line 4.A.) and private providers (Line 4.B.). Public providers are owned or operated by a State, county, city or other local governmental agency or instrumentality. Increasing adjustments related to private providers are considered current expenditures for the quarter in which the expenditure was made and are matched at the FMAP rate for that quarter. Increasing adjustments related to public providers are considered adjustments to prior period claims and are matched using the FMAP rate in effect at the earlier of the time the expenditure was paid or recorded by any State agency. (See 45 CFR Part 95 and §2560.)

4C

Intermediate Care Facility Services – Individuals with Intellectual Disabilities: Supplemental Payments

Line 4C. Intermediate Care Facility Services (ICF/IID) - Supplemental Payments (Refer to the definition on Line 4A above). These are payments made in addition to the standard fee schedule or other standard payment for those services. These payments are separate and apart from regular payments and are based on their own payment methodology. Payments may be made to all providers or targeted to specific groups or classes of providers. Groups may be defined by ownership type (state, county or private) and/or by the other characteristics, e.g., caseload, services or costs. The combined standard payment and supplemental payment cannot exceed the upper payment limit described in 42 CFR 447.272. Address supplemental payments for ICF/IID services associated with (1) state government operated facilities, (2) non-state government operated facilities, and (3) privately operated facilities by entering payments on the pop-up feeder form.

5A

Physician & Surgical Services - Reg. Payments

5A. - Physician and Surgical Services.--Regular Payments.-- (See 42 CFR 440.50.).--Whether furnished in the office, the recipient's home, a hospital, a NF, or elsewhere, physicians' services are services provided:

  • Within the scope of practice of medicine or osteopathy as defined by State law; and

  • By, or under, the personal supervision of an individual licensed under State law to practice medicine or osteopathy.

NOTE: Exclude all services provided and billed for by a hospital, clinic, or laboratory. Include any services provided and billed by a physician under physician services with the exception of lab and X-ray services. Include such services provided and billed for by a physician under the lab and X-ray services category. In a primary care case management system under a Freedom of Choice waiver, you sometimes use a physician as the case manager. In these situations, the physician is allowed to charge a flat fee for each person. Although this fee is not truly a physician service, report the expenditures for the fee on this line.

5B

Physician & Surgical Services - Sup. Payments

5B. - Physician and Surgical Services.--Supplemental Payments.-- (refer to definition for Line 5A above) Payments for physician and other practitioner services as defined in Line 5A that are made in addition to the standard fee schedule payment for those services. When combined with regular payments, these supplemental payments are equal to or less than the Federal upper payment limit. Address supplemental payments for physicians and practitioners associated with

  1. governmental hospitals or university teaching hospitals,

  2. private hospitals, and

  3. other supplemental payments by entering payment information on the pop-up feeder sheet.

5C

Physician & Surgical Services - Evaluation and Management

5C. Physician & Surgical Services - Evaluation and Management -- ACA Section 1202 - Services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System. 100% Federal Share Matching.

5D

Physician & Surgical Services - Vaccine codes

5D. Physician & Surgical Services - Vaccine codes -- ACA Section 1202 - Services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such system. 100% Federal Share Matching Rate

6A

Outpatient Hospital Services - Reg. Payments

6A. - Outpatient Hospital Services.--Regular Payments.-- (See 42 CFR 440.20.).--These are preventive, diagnostic, therapeutic, rehabilitative, or palliative services that:

  • Are furnished to outpatients;

  • Except in the case of nurse-midwife services (see 42 CFR 440.165), are furnished by, or under the direction of, a physician or dentist; and

  • Are furnished 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, meets the requirements for participation in Medicare. (See 42 CFR 440.165.)

6B

Outpatient Hospital Services - Sup. Payments

6B. - Outpatient Hospital Services.--Supplemental Payments.-- (refer to definition for Line 6A above) Payments for outpatient hospital services as defined in line 6A that are made in addition to the base fee schedule or other standard payment for those services. These payments are separate and apart from regular payments and are based on their own payment methodology. The combined standard payment and supplemental payment cannot exceed the Federal upper payment limit. Address outpatient hospital services supplemental payments associated with (1) state owned or operated hospitals, (2) non state government owned or operated hospitals and (3) private hospitals by entering payment information on the pop-up feeder sheet.

7

Prescribed Drugs

7 - Prescribed Drugs. (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:

  • Prescribed by a physician or other licensed practitioner of the healing arts within the scope of a professional practice as defined and limited by Federal and State law;

  • Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical Practice Act; and

  • Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained in the pharmacist's or practitioner's record.

7A1

Drug Rebate Offset - National

7.A.1. Drug Rebate Offset.--This is a refund from the manufacturer to the State Medical Assistance plan for single source drugs, innovator multiple source drugs, and non-innovator multiple source drugs that are dispensed to Medicaid recipients. Rebates are to take place quarterly. Report these offsets as (1) National Agreement or (2) State Sidebar Agreement. National Agreement refers to rebates manufacturers pay your State pursuant to the manufacturers' agreements with CMS under OBRA 1990 provisions. State Sidebar Agreements refer to rebates manufacturers pay under an agreement directly with your State. These may have been entered into before January 1, 1991, the effective date of the OBRA rebate program. Or they may represent agreements your State entered into with a given manufacturer on or after January 1, 1991, under which the manufacturer pays at least as great a rebate as it would under the National Agreement. All States receive rebates under the National Agreements. A few States receive most of their rebates under the National Agreement, but some States receive other rebates under their State Sidebar Agreement with specific manufacturers. All manufacturer rebates received under CMS's National Agreement are reported on Line 7.A.1, National Agreement. All rebates received under State Sidebar Agreements are reported on Line 7.A.2, State Sidebar Agreement.

NOTE: Vaccines are not subject to the rebate agreements.

7A2

Drug Rebate Offset - State Sidebar Agreement

7A2. Drug Rebate Offset.--This is the rebate collected under a separate State agreement Sidebar Agreement. These are rebates received that do not fall under 7A1 (National Drug Rebate).

7A3

MCO - National Agreement

7.A.3. National Agreement 7A3. Managed Care Organizations (MCO) – National Agreement: The Affordable Care Act requires manufacturers that participate in the Medicaid Drug Rebate Program to pay rebates for drugs dispensed to individuals enrolled with a Medicaid MCO if the MCO is responsible for coverage of such drugs, effective March 23, 2010. This is a refund from the manufacturer to the State Medical Assistance plan for single source drugs, innovator multiple source drugs, and non-innovator multiple source drugs that are dispensed to Medicaid recipients who are enrolled in a Medicaid MCO. Rebates are to take place quarterly. Report these offsets as MCO National Agreement. National Agreement refers to rebates manufacturers pay your State pursuant to the manufacturers agreements with CMS under OBRA 1990 provisions. All States receive rebates under the National Agreement. For rebates for Medicaid MCO drugs, there will be no rebates under their State Sidebar Agreement with specific manufacturers. All MCO manufacturer rebates received under CMS National Agreement are reported on Line 7.A.3, National Agreement NOTE: Vaccines are not subject to the National agreement.

7A4

MCO - State Sidebar Agreement

7.A.4. MCO State Sidebar Agreement. This is the rebate collected under a separate State agreement Sidebar Agreement. These are rebates received that do not fall under 7A3 (National Drug Rebate).

7A5

Increased ACA OFFSET - Fee for Service - 100%

7.A.5. Increased ACA OFFSET - Fee for Service - 100% Section 2501 of the Affordable Care Act increased the amount of rebates that drug manufacturers are required to pay under the Medicaid drug rebate program, with different formulas for single source and innovator multiple source drugs (brand name drugs) and noninnovator multiple source drugs (generic drugs), and drugs that are line extensions of a single source drug or an innovator multiple source drug, effective January 1, 2010. The Affordable Care Act also required that amounts “attributable” to these increased rebates be remitted to the Federal Government. Below is a description of how the offset is calculated: Brand name drugs other than blood clotting factors and drugs approved by the Food and Drug Administration (FDA) exclusively for pediatric indications are subject to a minimum rebate percentage of 23.1 percent of AMP:

  • If the difference between AMP and BP is less than or equal to 15.1 percent of AMP, then we plan to offset the full 8 percent of AMP (the difference between 23.1 percent of AMP and 15.1 percent of AMP).

  • If the difference between AMP and BP is greater than 15.1 percent of AMP, but less than 23.1 percent of AMP, then we plan to offset the difference between 23.1 percent of AMP and AMP minus BP.

  • If the difference between AMP and BP is greater than or equal to 23.1 percent of AMP, then we do not plan to take any offset amount.

Brand name drugs that are blood clotting factors and drugs approved by the FDA exclusively for pediatric indications are subject to a minimum rebate percentage of 17.1 percent of AMP:

  • If the difference between AMP and BP is less than or equal to 15.1 percent of AMP, then we plan to offset the full 2 percent of AMP (the difference between 17.1 percent of AMP and 15.1 percent of AMP).

  • If the difference between AMP and BP is greater than 15.1 percent of AMP, but less than 17.1 percent of AMP, then we plan to offset the difference between 17.1 percent of AMP and AMP minus BP.

  • If the difference between AMP and BP is greater than or equal to 17.1 percent of AMP, then we do not plan to take any offset amount.

For a drug that is a line extension of a brand name drug that is an oral solid dosage form, we plan to apply the same offset calculation as described above to the basic rebate. Further, we plan to offset only the difference in the additional rebate of the reformulated drug based on the calculation methodology of the additional rebate for the drug preceding the requirements of the Affordable Care Act and the calculation of the additional rebate for the reformulated drug, if greater, in accordance with the Affordable Care Act. If there is no difference in the additional rebate amount in accordance with the Affordable Care Act, then we do not plan to take any offset amount.

For a noninnovator multiple source drug, we plan to offset an amount equal to two percent of the AMP (the difference between 13 percent of AMP and 11 percent of AMP).

7A6

Increased ACA OFFSET - MCO - 100%

7.A.6. Increased ACA OFFSET - MCO - 100% 7A6. Increased ACA OFFSET – MCO: Similar to the increased ACA offset for fee-for-service, for covered outpatient drugs that are dispensed to Medicaid MCO enrollees, the Affordable Care Act also required that amounts “attributable” to the increased rebates be remitted to the Federal Government. Below is a description of how the offset is calculated: Brand name drugs other than blood clotting factors and drugs approved by the Food and Drug Administration (FDA) exclusively for pediatric indications are subject to a minimum rebate percentage of 23.1 percent of AMP:

  • If the difference between AMP and BP is less than or equal to 15.1 percent of AMP, then we plan to offset the full 8 percent of AMP (the difference between 23.1 percent of AMP and 15.1 percent of AMP).

  • If the difference between AMP and BP is greater than 15.1 percent of AMP, but less than 23.1 percent of AMP, then we plan to offset the difference between 23.1 percent of AMP and AMP minus BP.

  • If the difference between AMP and BP is greater than or equal to 23.1 percent of AMP, then we do not plan to take any offset amount.

Brand name drugs that are blood clotting factors and drugs approved by the FDA exclusively for pediatric indications are subject to a minimum rebate percentage of 17.1 percent of AMP:

  • If the difference between AMP and BP is less than or equal to 15.1 percent of AMP, then we plan to offset the full 2 percent of AMP (the difference between 17.1 percent of AMP and 15.1 percent of AMP).

  • If the difference between AMP and BP is greater than 15.1 percent of AMP, but less than 17.1 percent of AMP, then we plan to offset the difference between 17.1 percent of AMP and AMP minus BP.

  • If the difference between AMP and BP is greater than or equal to 17.1 percent of AMP, then we do not plan to take any offset amount.

For a drug that is a line extension of a brand name drug that is an oral solid dosage form, we plan to apply the same offset calculation as described above to the basic rebate. Further, we plan to offset only the difference in the additional rebate of the reformulated drug based on the calculation methodology of the additional rebate for the drug preceding the requirements of the Affordable Care Act and the calculation of the additional rebate for the reformulated drug, if greater, in accordance with the Affordable Care Act. If there is no difference in the additional rebate amount in accordance with the Affordable Care Act, then we do not plan to take any offset amount.

For a noninnovator multiple source drug, we plan to offset an amount equal to two percent of the AMP (the difference between 13 percent of AMP and 11 percent of AMP).

8

Dental Services

8. Dental Services (See 42 CFR 440.100.).--These are services that are diagnostic, preventive, or corrective procedures provided by, or under the supervision of, a dentist in the practice of his/her profession including treatment of:

  • The teeth and associated structures of the oral cavity; and

  • Disease, injury, or impairment that may affect the oral or general health of the recipient.

Report all EPSDT dental services on this line.

Dentist means an individual licensed to practice dentistry or dental surgery.

NOTE: Exclude all such services provided as part of inpatient hospital, outpatient hospital, nondental, clinic or laboratory services and billed for by the hospital, nondental clinic, or laboratory.

9A

Other Practitioners Services - Reg. Payments

9A. - Other Practitioners Services - Regular Payments (see CFR 440.60). Any medical or remedial care or services, other than physicians' services, provided by licensed practitioners with the scope of practice defined under State law. Chiropractors' services may be included here as long as the services that (1) are provided by a chiropractor who is licensed by the State and meets standards issued by the Secretary under section 405.232(b), and (2) consists of treatment by means of manual manipulation of the spine that the chiropractor is legally authorized by the State to perform.

9B

Other Practitioners Services - Sup. Payments

9B. - Other Practitioners Services - Supplemental Payments Payments for other practitioner services as defined in Line 9A that are made in addition to the standard fee schedule payment for those services. When combined with regular payments, these supplemental payments are equal to or less than the Federal upper payment limit. Address supplemental payments for other practitioners associated with (1) governmental hospitals or university medical schools, and (2) private hospitals or university medical schools, and (3) other supplemental payments by entering payment information on the pop-up feeder sheet.

10

Clinic Services

10. Clinic Services (See 42 CFR 440.90.).--These are preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that:

  • Are provided to outpatients;

  • Are provided by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. For reporting purposes, consider a group of physicians who share, only for mutual convenience, space, services of supporting staff, etc., as physicians, rather than a clinic, even though they practice under the name of a clinic; and

  • 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 clinics under Dental Services. Report any services not included above under Other Care Services. A clinic staff may include practitioners with different specialties.

11

Laboratory/Radiological

11. Laboratory And Radiological Services (See 42 CFR 440.30.).--These are professional, technical laboratory and radiological services:

  • Ordered and provided by, or under, the direction of a physician or other licensed practitioner of the healing arts within the scope of a practice as defined by State law or ordered and billed by a physician but provided by an independent laboratory;

  • Provided in an office or similar facility other than a hospital inpatient or outpatient department or clinic; and

  • Provided by a laboratory that meets the requirements for participation in Medicare.

NOTE: Report X-rays by dentists under Dental Services, Line 8.

12

Home Health Services

12, Home Health Services (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 renewed every 60 days and includes the following items and services:

  • Nursing service as defined in the State Nurse Practice Act, that is provided on a part-time or intermittent basis by a home health agency (HHA) (a public or private agency or organization, or part of an 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 case and services provided; and

  • Has had orientation to acceptable clinical and administrative record keeping from a health department nurse.

  • Home health aide services provided by an HHA;

  • Medical supplies, equipment, and appliances suitable for use in the home; and

  • Physical therapy, occupational therapy, or speech pathology and audiology services provided by an HHA or by a facility licensed by the State to provide medical rehabilitation services. (See 42 CFR 441.15 - Home Health Services.)

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.

13

Sterilizations

13. Sterilizations (See 42 CFR 441, Subpart F.).--These are medical procedures, treatments, or operations for the primary purpose of rendering an individual permanently incapable of reproducing.

14

Other Pregnancy-related Procedures

14. Other Pregnancy-related Procedures (See 42 CFR 441, Subpart E.).--FFP is available when a physician has certified, in writing, to the Medicaid agency, that on the basis of professional judgment the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless a termination is performed. The certification must contain the name and address of the patient.

The revision to the Hyde Amendment, P.L. 103-112, Health and Human Services Appropriations Bill, made FFP available for expenditures for other pregnancy-related procedures when the pregnancy is a result of an act of rape or incest. This reimbursement is effective for dates of service October 1, 1993 and thereafter.

Provide a breakout of the number of other pregnancy-related procedures and associated expenditures in the following cases:

  • Procedures performed to save the life of the mother,

  • Procedures performed in the case of pregnancies resulting from incest, and

  • Procedures performed in the case of pregnancies resulting from rape.

NOTE 1: Report all other pregnancy-related procedures on this line regardless of the type of provider. For prior period adjustments, only include any entry in number of procedures if, for increasing claims, it is a new pregnancy-related procedure that has not been previously reported, or, for decreasing claims, you want to remove a procedure previously claimed. Make no entry in number of procedures if all you are changing is the dollar amount claimed.

NOTE 2: The "morning after pill" (ECP) is not considered a termination as it is a contraceptive to prevent pregnancy. However, the drug Mifepristone (RU486) should be counted as an other pregnancy-related procedure as long as all Hyde amendment and other federal requirements are met.

15

EPSDT Screening

15. EPSDT Screening Services - Physical and mental assessment given to Medicaid eligibles under age 21 to carry out the screening provisions of the EPSDT program. However, the agency must provide at least the following services through consultation with health experts, determine the specific health evaluation procedures to be used, and the mechanisms needed to carry out the screening program.

  • A comprehensive health and developmental history (including assessment of both physical and mental health development);

  • A comprehensive unclothed physical exam;

  • Appropriate immunizations according to the Advisory Committee on Immunization Practices

  • Laboratory tests (including blood lead level assessment according to age/risk factors);

  • Health education (including anticipatory guidance); and

  • Dental Services - Referral to a dentist in accordance with the States’ periodicity schedule.

  • Vision Services

The above services may be provided by any qualified Medicaid provider.

NOTE: Do not include data for dental, hearing, or vision services here. Report dental examinations and preventative dental services on Line 8, Dental Services. Report hearing services, including hearing aids, on Line 32, Services for Speech, Hearing and Language. Report vision services rendered by professionals (e.g. – examinations, etc.) on Line 9, Other Practitioners' Services. Note that the cost of eyeglasses and other aids to vision is to be reported on Line 33, Prosthetic Devices, Dentures, and Eyeglasses. Report other necessary health care according to the appropriate category.

16

Rural Health

16. Rural Health Clinic (RHC) Services (See 42 CFR 440.20(b).).--If a State permits the delivery of primary care by a nurse practitioner (NP) or physician's assistant (PA), rural health clinic (RHC) means the following services furnished by a RHC that has been certified in accordance with the conditions of 42 CFR Part 491 (Certification of Certain Health Facilities):

  • Services furnished by a physician within a professional scope under State law, whether the physician performs these services in or away from the clinic and the physician has an agreement with the clinic to be paid by it for such services.

  • Services furnished by a PA, NP, nurse midwife or other specialized NP (as defined in 42 CFR 405.2401 and 491.2) if they are furnished in accordance with the requirements specified in 42 CFR 405.2414(a).

  • Services and supplies that are furnished as incident to professional services furnished by a physician, PA, NP, nurse midwife, or specialized NP. (See 42 CFR 405.2413 and 405.2415 for the criteria determining whether services and supplies are included.)

  • Part-time or intermittent visiting nurse care and related medical supplies (other than drugs and biological) if:

  • The clinic is located in an area in which the Secretary has determined that there is a shortage of HHAs (see 42 CFR 405.2417);

  • The services are furnished by an RN or licensed PN or a licensed vocational nurse employed by, or otherwise compensated for the services by, the clinic;

  • The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic or that is established by a physician, PA, NP, nurse midwife, or specialized NP and reviewed and approved at least every 60 days by a supervising physician of the clinic; and

  • The services are furnished to a homebound recipient. 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, place of residence does not include a hospital or an NF.Rural Health Clinic (RHC) Services (See 42 CFR 440.20(b).).--If a State permits the delivery of primary care by a nurse practitioner (NP) or physician's assistant (PA), rural health clinic (RHC) means the following services furnished by a RHC that has been certified in accordance with the conditions of 42 CFR Part 491 (Certification of Certain Health Facilities):

  • Services furnished by a physician within a professional scope under State law, whether the physician performs these services in or away from the clinic and the physician has an agreement with the clinic to be paid by it for such services.

  • Services furnished by a PA, NP, nurse midwife or other specialized NP (as defined in 42 CFR 405.2401 and 491.2) if they are furnished in accordance with the requirements specified in 42 CFR 405.2414(a).

  • Services and supplies that are furnished as incident to professional services furnished by a physician, PA, NP, nurse midwife, or specialized NP. (See 42 CFR 405.2413 and 405.2415 for the criteria determining whether services and supplies are included.)

  • Part-time or intermittent visiting nurse care and related medical supplies (other than drugs and biological) if:

  • The clinic is located in an area in which the Secretary has determined that there is a shortage of HHAs (see 42 CFR 405.2417);

  • The services are furnished by an RN or licensed PN or a licensed vocational nurse employed by, or otherwise compensated for the services by, the clinic;

  • The services are furnished under a written plan of treatment that is established and reviewed at least every 60 days by a supervising physician of the clinic or that is established by a physician, PA, NP, nurse midwife, or specialized NP and reviewed and approved at least every 60 days by a supervising physician of the clinic; and

  • The services are furnished to a homebound recipient. 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, place of residence does not include a hospital or an NF.

17A

Medicare - Part A

17A. Part A Premiums--(See §301 P.L. 100-360 and §1902 (a)(10) (E)(ii) of the Act)-- Include Part A premiums paid for Qualified Disabled and Working Individuals (QWDIs) under §1902(a)(10)(E)(ii) of the Act.

17B

Medicare - Part B

17B. Part B Premiums--(See §1902(a). Part B Premiums - Include premiums paid through Medicare buy-in under 1843 for Qualified Medicare Beneficiaries (QMBs) under 1902(a)(10)(E)(i),Specified Low-Income Medicare Beneficiaries (SLMBs) under 1902(a)(10)(E)(iii),and other Medicare/Medicaid dual eligibles covered in 1902(a)(10) of the Act. Do not include part B premiums for line 17C (Qualifying Individuals). This amount is shown on the bottom of each monthly bill sent to you on the summary accounting statement Form CMS-1604.

17C1

120% - 134% Of Poverty

Line 17C.1. - 120% - 134% of Poverty - Include premiums paid for Medicare Part B under §1902(a)(10)(E)(iv)(I).

17D

Coinsurance

17D. Coinsurance and Deductibles-- Include Medicare deductibles and coinsurance required to be paid for QMBs under §1905 (p)(3). (Do not include any Medicare deductibles and coinsurance for other Medicare/Medicaid dual eligibles. Report expenditures for Medicaid services also covered by Medicare under the appropriate Medicaid service category.) Coinsurance is a joint assumption of risk by the insured and the insurer, whereby each shares on a specific basis, the applicable medical expenses of the insured. The insured's share of coinsurance may be paid on his/her behalf. For example, under part B of Medicare, the beneficiary's coinsurance responsibility is a percent of reasonable and customary expenses greater than the stipulated deductible. A deductible is that portion of applicable medical expenses which must be borne by the insured (or be paid on his/her behalf) before insurance benefits for the calendar year begin.

EXCEPTION: REPORT ALL OTHER PREGNANCY-RELATED PROCEDURES ON LINE 14.

18A

Medicaid - MCO

18A. Managed Care Organizations (MCOs)-- (See §1903(m)(1)(A) of the Act revised by BBA §4701(b)). - Include capitated payments made to a Medicaid Managed Care Organization which is defined as follows:

A Medicaid Managed Care Organization (MCO) means a health maintenance organization, an eligible organization with a contract under §1876 or a Medicare+ Choice organization with a contract under part C of title XVIII, a provider sponsored organization, which meets the requirements of §1902(w)and -

  1. makes services it provides to individuals eligible for benefits under this title accessible to such individuals, within the area served by the organization, to the same extent as such services are made accessible to individuals (eligible for Medical Assistance under the State plan) not enrolled with the organization, and

  2. has made adequate provision against the risk of insolvency, which provision is satisfactory to the State and which assures that individuals eligible for benefits under this title are in no case held liable for debts of the organization in case of the organization's insolvency.

An organization that is a qualified health maintenance organization ( as defined in §1310(d) of the Public Health Service Act) is deemed to meet the requirements of clauses (i) and (ii).

18A1

Medicaid MCO - Evaluation and Management

18A1. Medicaid MCO - Evaluation and Management -- ACA Section 1202 - Services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System. 100% Federal Share Matching.

18A2

Medicaid MCO - Vaccine codes

18A2. Medicaid MCO - Vaccine codes -- ACA Section 1202 - Services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such system. 100% Federal Share matching rate

18A3

Medicaid MCO - Community First Choice

18A3. Medicaid MCO - Community First Choice -- 6% FMAP rate for Total Computable entered at the FMAP Federal Share rate. ACA Section 2401 - The provision established a new Medicaid State Plan option effective October 1, 2011 to allow States to cover HCBS and supports for individuals with incomes not exceeding 150 percent of the FPL, or, if greater, who have been determined to require an institutional level of care. States are provided an additional 6% increase in the FMAP matching funds for services and supports provided to such individuals.

18A4

Medicaid MCO - Preventive Services Grade A OR B, ACIP Vaccines and their Admin

18A4. Medicaid MCO - Preventive Services Grade A or B, ACIP Vaccines and their Admin -- 1% FMAP rate for Total Computable entered at the FMAP Federal Share rate. As a result of ACA 4106 Any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force. States get the 1% additional FMAP upon an approved SPA. Effective January 1, 2013

18B1

Prepaid Ambulatory Health Plan

A Prepaid Ambulatory Health Plan (PAHP) means an entity that provides medical services to enrollees under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates. A PAHP does not provide or arrange for the provision of any inpatient hospital or institutional services for its enrollees, and does not have a comprehensive risk contract.

NOTE: Include dental, mental health, transportation and other plans covering limited services (without inpatient hospital or institutional services) under PAHP.

18B1a

MCO PAHP - Evaluation and Management

18B1a. MCO PAHP - Evaluation and Management -- ACA Section 1202 - Services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System. 100% Federal Share Matching.

18B1b

MCO PAHP - Vaccine codes

18B1b. MCO PAHP - Vaccine codes -- ACA Section 1202 - Services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such system. 100% Federal Share matching rate

18B1c

MCO PAHP - Community First Choice

18B1c. MCO PAHP - Community First Choice -- 6% FMAP rate for Total Computable entered at the FMAP Federal Share rate. ACA Section 2401 - The provision established a new Medicaid State Plan option effective October 1, 2011 to allow States to cover HCBS and supports for individuals with incomes not exceeding 150 percent of the FPL, or, if greater, who have been determined to require an institutional level of care. States are provided an additional 6% increase in the FMAP matching funds for services and supports provided to such individuals.

18B1d

MCO PAHP - Preventive Services Grade A OR B, ACIP Vaccines and their Admin

18B1d. MCO PAHP. Preventive Services Grade A OR B, ACIP Vaccines and their Admin -- 1% FMAP rate for Total Computable entered at the FMAP Federal Share rate. As a result of ACA 4106 Any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force. States get the 1% additional FMAP upon an approved SPA. Effective January 1,

18B2

Prepaid Inpatient Health Plan

A Prepaid Inpatient Health Plan (PIHP) means an entity that provides medical services to enrollees under contract with the State agency, and on the basis of prepaid capitation payments, or other payment arrangements that do not use State plan payment rates. A PIHP provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its enrollees. A PIHP does not have a comprehensive risk contract.

NOTE: Include dental, mental health, transportation and other plans covering limited services (with inpatient hospital or institutional services) under PIHP.

18B2a

MCO PIHP - Evaluation and Management

18B2a. MCO PIHP - Evaluation and Management -- ACA Section 1202 - Services in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System. 100% Federal Share Matching.

18B2b

MCO PIHP - Vaccine codes

18B2b. MCO PIHP - Vaccine codes -- ACA Section 1202 - Services related to immunization administration for vaccines and toxoids for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as subsequently modified) apply under such system. 100% Federal Share matching rate

18B2c

MCO PIHP - Community First Choice

18B2c. MCO PIHP - Community First Choice -- 6% FMAP rate for Total Computable entered at the FMAP Federal Share rate. ACA Section 2401 - The provision establishes a new Medicaid State Plan option effective October 1, 2011 to allow States to cover HCBS and supports for individuals with incomes not exceeding 150 percent of the FPL, or, if greater, who have been determined to require an institutional level of care. States are provided an additional 6% increase in the FMAP matching funds for services and supports provided to such individuals.

18B2d

MCO PIHP - Preventive Services Grade A OR B, ACIP Vaccines and their Admin

18B2d. MCO PIHP. Preventive Services Grade A OR B, ACIP Vaccines and their Admin -- 1% FMAP rate for Total Computable entered at the FMAP Federal Share rate. As a result of ACA 4106 Any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force. States get the 1% additional FMAP upon an approved SPA. Effective January 1,

18C

Medicaid - Group Health

18C. Group Health Plan Payments-- Include payments for premiums for cost effective employer group health insurance under §1906 of the Act.

18D

Medicaid - Coinsurance

18D. Coinsurance and Deductibles-- Include payments for coinsurance and deductibles for cost employer group health insurance under §1906 of the Act.

18E

Medicaid - Other

18E. Other--Include premiums paid for other insurance for medical or any other type of remedial care in order to maintain a third party resource under §1905(a). (Report expenditures here only if you have elected to pay these premiums in item 3.2(a)(2) on page 29b of your State Plan Preprint.)

EXCEPTION: REPORT ALL OTHER PREGNANCY-RELATED PROCEDURES ON LINE 14.

19A

Home & Community-Based Services - Reg. Pay. (Waiv)

19A. Home and Community-Based Services (See 42 CFR 440.180.(a).).--These are services furnished under a 1915(c) waiver approved under the provisions in 42 CFR 441, Subpart G (Home and Community-Based Services; Waiver Requirements).

NOTE: Report only approved waiver services as designated in the State's approved waiver applications which are provided to eligible waiver recipients.

19B

Home & Community-Based Services - St. Plan 1915(i) Only Pay.

19B. - Other Practitioners Services - State Plan 1915(i) Only Payment. Only the home and community based services elected and defined in the approved State plan may be claimed on this line and form. Enter cost data on the lines in the pop-up feeder sheet that match the services approved in the State plan.

19C

Home & Community-Based Services - St. Plan 1915(j) Only Pay.

19C Home and Community Based Services – State Plan 1915(j) Only Payment – 42 CFR Part 441 – Self-Directed Personal Assistance Services Program State Plan Option. These are PAS services provided under the self-directed service delivery model authorized by 1915(j) including any approved home and community-based services otherwise available under a 1915(c) waiver. The MBES will automatically enter in row 19C the totals from the pop-up 1915(j) Self-Directed Personal Assistance Services Feeder Form. Expenditures for 1915(c) waiver like services provided under 1915(j) Self Direction are entered on the line 19C Feeder Form rather than on the Line 19A Waiver Form which is reserved for approved waiver expenditures.

NOTE: 1915(j) services that are using the self-directed service delivery model for State Plan Personal Care and related services should be claimed separately on Line 23B.

19D

Home & Community Based Services State Plan 1915(k) Community First Choice

19D Home and Community Based Services State Plan 1915(k) Community First Choice ACA Section 2401 - The provision established a new Medicaid State Plan option effective October 1, 2011 to allow States to cover HCBS and supports for individuals with incomes not exceeding 150 percent of the FPL, or, if greater, who have been determined to require an institutional level of care. States are provided an additional 6% increase in the FMAP matching funds for services and supports provided to such individuals.

22

All-Inclusive Care Elderly

22. Programs of All-Inclusive Care for the Elderly (PACE)(See 42 CFR Part 460).--PACE provides pre-paid, capitated, comprehensive health care services designed to enhance the quality of life and autonomy for frail, older adults. Required services (See 42 CFR 460.92) The PACE benefit package for all participants, must include:

  1. All Medicaid-covered services, as specified in the State's approved Medicaid plan.

NOTE: This is an option within the Medicaid Program to establish Programs of All-Inclusive Care for the Elderly beginning August 5, 1998. (See §1905(a)(26) and §1934 of the Act.) Do not report payments for PACE programs which continue to operate under §1115 authority on this line. Report payments for PACE programs continuing to operate under §1115 waiver authority on the appropriate waiver forms under the appropriate categories of services.

23A

Personal Care Services - Reg. Payments

23A. - Personal Care Services.--Regular Payment.-- (See 42 CFR 440.167).-- Unless defined differently by a State agency for purposes of a waiver granted under Part 441, subpart G of this chapter

Personal care services means services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or institution for mental health conditions that are--

  1. 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;

  2. Provided by an individual who is qualified to provide such services and who is not a member of the individual's family; and

  3. Furnished in a home, and at the State's option in another location.

23B

Personal Care Services - SDS 1915(j)

23B. - Personal Care Services.--SDS 1915(j).-- (See 42 CFR Part 441).-- Self-Directed Personal Assistance Services (PAS) State Plan Option. These are PAS provided under the self-directed service delivery model authorized by 1915(j) for State plan personal care and related services.

NOTE: 1915(j) PAS that are using the self-directed service delivery model for section 1915(c) home and community-based services should be claimed separately on line 19C.

24A

Targeted Case Management Services - Com. Case-Man.

24A. - Targeted Case Management Services (see section 1915(g)(1) of the Social Security Act) are case management services that are furnished without regard to the requirements of section 1902(a)(1) and section 1902(a)(10)(B) to specific classes of individuals or to individuals who reside in specified areas. Case management services means services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services (See section 1915(g)(2) of the Act).

24B

Case Management - State Wide

24B. - Case Management.--State Wide.-- (See §1915(g)(2) of the Act.).--These are services that assist individuals eligible under the State plan in gaining access to needed medical, social, educational and other services. The agency must permit individuals to freely choose any qualified Medicaid provider when obtaining case management services in accordance with 42 CFR 431.51.

25

Primary Care Case Management

25. Primary Care Case Management Services (PCCM) (See §1905(a)(25) and §1905 (t)--These are case-management related services (including locating, coordinating, and monitoring of health care services) provided by a primary care case manager under a primary care case management contract. Currently most PCCM programs pay the primary care case manager a monthly case management fee. Report service costs and/or related fees on this line. Report other service costs and/or related fees on the appropriate type of service line.

NOTE: Where the fee includes services beyond case management, report the fees under line 18B.

26

Hospice Benefits

26 - Hospice Benefits (See Section1905(o)(1)(A) of the Act.).--The care described in section 1861(dd)(1) furnished by a hospice program (as defined in section 1861(dd)(2)) to a terminally ill individual who has voluntarily elected to have payment made for hospice care instead of having payment made for certain benefits described under 1812(d)(2)(A) and for which payment may otherwise be made under Title XVIII and intermediate care facility services under the plan. Hospice care may be provided to an individual while such individual is a resident of a skilled nursing facility or intermediate care facility, but the only payment made under the State plan shall be for the hospice care.

NOTE: These are services that are:

  • Covered in 42 CFR 418.202;

  • Furnished to a terminally ill individual, as defined in 42 CFR 418.3;

  • 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;

  • Furnished under a written plan that is established and periodically reviewed by:

  • The attending physician;

  • The medical director of the program, as described in 42 CFR 418.54; or

  • The interdisciplinary group described in 42 CFR 418.68.

27

Emergency Services for Undocumented Aliens

27. Emergency Services Undocumented Aliens Pursuant to the Act The Medicaid program pays for emergency medical services provided to certain aliens. Section §1903(v) of the Act sates that "...no payment may be made to a State under this section for medical assistance furnished to an alien who is not lawfully admitted... " The only exception is if such care and services are for

  1. an emergency medical condition,

  2. if such alien otherwise meets the eligibility requirements for medical assistance under the State Plan, and

  3. such care and services are not related to an organ transplant procedure.

28

Federally-Qualified Health Center

28. Federally-Qualified Health Center (FQHC) (See §1905(a)(2) of the Act.) --These are services performed by facilities or programs more commonly known as Community Health Centers, Migrant Health Centers, and Health Care for the Homeless Programs. FQHCs qualify to provide covered services under Medicaid if:

  • They receive grants under §§329, 330, or 340 of the Public Health Service (PHS) Act;

  • The Health Resources and Services Administration, PHS certifies the center as meeting FQHC requirements; or

  • The Secretary determines that the center qualifies through waiver of the requirements.

29

Non-Emergency Medical Transportation

29. - Non-Emergency Medical Transportation (see 42CFR431.53; 440.170; 440.170(a); 440.170(a)(4))--A ride, or reimbursement for a ride, provided so that a Medicaid beneficiary with no other transportation resources can receive services from a medical provider. (NEMT does not include transportation provided on an emergency basis, such as trips to the emergency room for life-threatening situations.

NOTE: Transportation provided via the State is consider an administrative cost and should be reported on the form CMS-64.10.

30

Physical Therapy

30. - Physical Therapy (See 42CFR440.110(a)(1)).--Services prescribed by a physician or other licensed practitioner of the healing arts 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. It includes any necessary supplies and equipment.

NOTE: Do not include any costs for physical therapy services provided under the school based environment. Those costs should be reported on the pop-up feeder form for Line 39 below.

NOTE: Do not include any costs for physical therapy services provided under the rehabilitative services option. Those costs should be reported on the pop-up feeder form for Line 40 below.

31

Occupational Therapy

31. - Occupational Therapy (see 42CFR440.110(b))--Occupational therapy means services prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a recipient by or under the direction of a qualified occupational therapist. It includes any necessary supplies and equipment.

NOTE: Do not include any costs for occupational therapy services provided under the school based environment. Those costs should be reported on the pop-up feeder form for Line 39 below.

NOTE: Do not include any costs for occupational therapy services provided under the rehabilitative services option. Those costs should be reported on the pop-up feeder form for Line 40 below.

32

Services for Speech, Hearing & Language

32. - Services for Speech, Hearing and Language--Services for individuals with speech, hearing, and language disorders (See 42CFR440.110(c)). Services for individuals with speech, hearing, and language disorders means diagnostic, screening, preventive, or correction services provided by or under the direction of a speech pathologist or audiologist, for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law. It includes any necessary supplies and equipment, including hearing aids.

NOTE: Do not include any costs for speech and language services provided under the school based environment. Those costs should be reported on the pop-up feeder form for Line 39 below.

NOTE: Do not include any costs for speech / language therapy services provided under the rehabilitative services option. Those costs should be reported on the pop-up feeder form for Line 40 below. . It includes any necessary supplies and equipment.

33

Prosthetic Devices, Dentures, Eyeglasses

Line 33 - Prosthetic Devices, Dentures, Eyeglasses (See 42 CFR 440.120)

Prosthetic devises means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner to:

1. Artificially replace a missing portion of the body;

2. Prevent or correct physical deformity or malfunction;

3. Support a weak or deformed portion of the body.

Dentures are artificial structures made by or under the direction of a dentist to replace a full or partial set of teeth.

Eyeglasses means lenses, including frames, and other aids to vision prescribed by a physician skilled in diseases of the eye or an optometrist.

34

Diagnostic Screening & Preventive Services

34. - Diagnostic Screening & Preventive Services (see 42CFR440.130)

  1. "Diagnostic services", except as otherwise provided under this subpart, includes any medical procedures or supplies recommended by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law, to enable him to identify the existence, nature, or extent of illness, injury, or other health deviation in a recipient.

  2. "Screening services" means the use of standardized tests given under medical direction in the mass examination of a designated population to detect the existence of one or more particular diseases or health deviations or to identify for more definitive studies individuals suspected of having certain diseases.

  3. "Preventive services" means services provided by a physician or other licensed practitioner of the healing arts within the scope of his practice under State law to:

    1. Prevent disease, disability, and other health conditions or their progression;

    2. Prolong life; and

    3. Promote physical and mental health and efficiency.

NOTE: This does not include Rehabilitative services - those services are reported on the pop-up feeder sheet for line 40 below.

34A

Preventive Services Grade A OR B, ACIP Vaccines and their Admin

34A. Preventive Services Grade A OR B, ACIP Vaccines and their Admin -- 1% FMAP rate for Total Computable entered at the FMAP Federal Share rate. As a result of ACA 4106- Any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force. States get the 1% additional FMAP upon an approved SPA. Effective January 1, 2013

35

Nurse Mid-Wife

Line 35 - Nurse Mid-Wife (See 42 CFR 440.165) "Nurse-midwife services" means services that are furnished within the scope or practice authorized by State law or regulation and, in the case of inpatient or outpatient hospital services or clinic services, are furnished by or under the direction of a nurse mid-wife to the extent permitted by the facility. Unless required by required by State law or regulations or a facility, are reimbursed without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider. See 42 CFR 441.21 for provisions on independent provider agreements for nurse-midwives.

36

Emergency Hospital Services

36. - Emergency Hospital Services (See 42 CFR 440.170) Emergency hospital services means services that:

  1. Are necessary to prevent the death or serious impairment of the health of the recipient; and

  2. Because of the threat to the life or health of the recipient necessitate the use of the most accessible hospital available that is equipped to furnish the services, even if the hospital does not currently meet- (i) The conditions for participation under Medicare; or (ii) The definitions of inpatient or outpatient hospital services under 42 CFR 440.10 and 440.20. NOTE: Emergency health services provided to undocumented aliens and funded under an allotment established under §4723 of the Balanced Budget Act of 1997 P.L. 105-33 should be reported on Line 27.

37

Critical Access Hospitals

Line 37 - Critical Access Hospitals (See 42 CFR 440.170) -- Critical access hospital services that are furnished by a provider that meet the requirements for participation in Medicare as a CAH (see subpart F of 42 CFR part 485), and (ii) are of a type that would be paid for by Medicare when furnished to a Medicare beneficiary. Inpatient CAH services do not include nursing facility services furnished by a CAH with a swing-bed approval.

38

Nurse Practitioner Services

Line 38 - Nurse Practitioner Services (See 42 CFR 440.166) Nurse practitioner services means services that are furnished by a registered professional nurse who meets a 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. See 42 CFR 440.166 for requirements related to certified pediatric nurse practitioner and certified family nurse practitioner.

39

School Based Services

39. - School Based Services (See section 1903(c) of the Act)--These services include medical assistance for covered services (see section 1905(a)) furnished to a child with a disability because such services are included in the child's individualized educational program established pursuant to Part B of the Individuals with Disabilities Education Act or furnished to an infant or toddler with a disability because such services are included in the child's individualized family service plan.

40

Rehabilitative Services (non-school-based)

40. - Rehabilitative Services (non-school-based) (see 42CFR440.130(d))--Except as otherwise provided under this subpart, rehabilitative services includes any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, with the scope of his practice under State law, for maximum reduction of physical or mental health condition and restoration of a recipient to his best possible functional level.

NOTE: Do not include any costs for rehabilitative services provided under the school based environment which should be reported on Line 39.

41

Private Duty Nursing

41. - Private Duty Nursing (see 42CFR440.80)--Nursing services for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or skilled nursing facility. These services are provided:

  1. by a registered nurse or a licensed practical nurse;

  2. under the direction of the recipient's physician ; and

  3. to a recipient in one or more of the following locations at the option of the State:

    1. his or her own home;

    2. a hospital; or

    3. a skilled nursing facility.

42

Freestanding Birth Center

Line 42 - Freestanding Birth Center -- COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES Section 2301 of the Affordable Care Act amended section 1905(a) of the Social Security Act (the Act) to provide coverage for freestanding birth center services, as defined in section 1905(l)(3)(A) of the Act. In that provision, the benefit is defined as services furnished at a freestanding birth center, which is defined in new subparagraph 1905(l)(3)(B) as a health facility:

  • that is not a hospital;

  • where childbirth is planned to occur away from the pregnant woman’s residence;

  • that is licensed or otherwise approved by the State to provide prenatal, labor and delivery, or postpartum care and other ambulatory services included in the State plan; and

  • that must comply with a State’s requirements relating to the health and safety of individuals receiving services delivered by the facility.

In addition to payment for freestanding birth center facilities, section 1905(l)(3)(C) of the Act requires separate payment for the services furnished by practitioners providing prenatal, labor and delivery, or postpartum care in a freestanding birth center facility, such as nurse midwives and birth attendants. Payment must be made to these practitioners directly, regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. It is important to note that section 2301 of the Affordable Care Act does not require States to license or otherwise recognize freestanding birth centers or practitioners who provide services in these facilities if they do not already do so. Coverage and payment are limited to only those facilities and practitioners licensed or otherwise recognized under State law.

Prior to passage of the Affordable Care Act, only nurse midwife services were mandatory services under section 1905(a)(17) of the Act and implementing regulations at 42 CFR 440.165. In addition, States had the option to cover the services of other practitioners who are licensed by the State to provide midwifery services such as Certified Professional Midwives (CPM) under section 1905(a)(6) of the Act and implementing regulations at 42 CFR 440.60. These practitioner services are now mandatory when provided in a freestanding birth center as defined above. Further, other practitioner services, such as those furnished by so-called direct entry or lay midwives or birth attendants, who are not licensed but are recognized under State law to provide these services, are now required to be covered when provided in the freestanding birth center.

Submission of State Plan Amendments These provisions became effective with the enactment of the Affordable Care Act, beginning March 23, 2010. To implement these provisions, States will need to submit amendments to their State plans that specify coverage and separate reimbursement of freestanding birth center facility services and professional services. Unless the compliance exception discussed below applies, or the State does not license or otherwise recognize freestanding birth centers or practitioners who provide services in these facilities, States must submit a State plan amendment (SPA) not later than the end of the next calendar quarter that follows the date of this guidance. In accordance with section 2301(c) of the Affordable Care Act, States that require State legislation (other than appropriation legislation) to meet the new requirements related to their Medicaid coverage of freestanding birth center services will not be regarded as out of compliance with the standards governing this coverage option as long as they come into compliance not later than the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of the Affordable Care Act. For example, if the next regular legislative session beginning after March 23, 2010, is from January 1 through April 30, 2011, then the State would have until September 30, 2011, to submit the required SPA with an effective date of July 1, 2011. In the case of the State that has a 2-year legislative session, each year is treated as a separate regular session of the State legislature. For example, if a legislature is in session from January 1, 2010, through December 31, 2012, then the State would have until March 31, 2011, to submit a SPA with an effective date that is no later than January 1, 2011. A State should promptly notify its CMS regional office if this compliance exception is applicable. We encourage any State that has questions about this guidance to contact Ms. Vikki Wachino, Director, Family and Children’s Health Programs Group, who may be reached at 410-786-5647. As always, CMS is available to help in making changes to your State plan. Please contact your servicing CMS regional office should you want to schedule a technical assistance session

43

Health Home for Enrollees w Chronic Conditions

43. Health Home for Enrollees w Chronic Conditions - Health Home services which includes - Comprehensive care Management - Care Coordination - Health promotion - Comprehensive transitional care (Planning and coordination) - Individual and Family Support - Referral to community/social supports - Use of Health Information Technology to link services as feasible and appropriate

44

Tobacco Cessation for Pregnant Women

44. Tobacco Cessation for Preg Women - ACA Section 4107 Payments for tobacco cessation counseling services for pregnant women and smoking/tobacco cessation outpatient drugs for pregnant women.

49

Other Care Services

49 -- Other Care Services --These are any medical or remedial care services recognized under State law and authorized by the approved Medicaid State Plan. Such services do not meet the definition of, and are not classified under, any category of service included on Lines 1 through 41.

50

Total

Line 50 – TOTAL -The MBES automatically enters the total of Columns (a)- (e).



Appendix J: MBES CBES Category of Service Line Definitions for the 21 Form

Line

Line - Form Display

Line - Definition

1A

Premiums - Up To 150%: Gross Premiums Paid

Line 1.A. Gross Premiums Paid.--Report on line 1.A. the amount of expenditures related to premiums paid for children whose family income is up to 150 percent of the Federal poverty level. Use the definition as contained in Part 2 Section 2500.2.E., lines 18.A. -18.E. (Medicaid Health Insurance Payments-Health Maintenance Organizations (HMO), Health Insuring Organization (HIO), Prepaid Health Plans (PHP), Group Health Plan Payments, and Other, respectively) of the State Medicaid Manual. Remember to report the total amount of the premiums. DO NOT NET THE OFFSETS WITH THE PREMIUMS. For example, it costs the State 500 per month per person and there are 100 people under this plan. Assume that the state receives $20 from one of the individuals covered for his share of the cost. Report $50,000 (500 x 100) on Line 1.A. and $20 on Line 1.B.

1B

Premiums - Up To 150%: Cost Sharing Offset

Line 1.B. Cost Sharing Offsets.--Report any cost sharing offset amounts received with respect to the amounts reported on Line 1.A. for children whose family income is up to 150 percent of the Federal poverty level. As indicated above, for line 1.A, the cost sharing offset amounts relate to the expenditures reported on line 1.A. should be reported separately on line 1.B.

1C

I Premiums - Over 150%: Gross Premiums Paid

Line 1.C. Gross Premiums Paid.--For children above 150% of poverty, premiums may be imposed on a sliding scale related to family income. Use the definition as contained in Part 2 Section 2500.2.E., lines 18.A. -.18.E (Medicaid Health Insurance Payments-Health Maintenance Organizations (HMO), Health Insuring Organization (HIO), Prepaid Health Plans (PHP), Group Health Plan Payments, and Other, respectively) of the State Medicaid Manual. DO NOT NET THE OFFSETS WITH THE PREMIUMS For an example see item 1.A.

1D

Premiums - Over 150%: Cost Sharing Offset

Line 1.D. Cost Sharing Offsets.--Report any cost sharing offset amounts received with respect to the amounts reported on line 1.C. for children whose family income is above 150 percent of the Federal poverty level. As indicated above for line 1.A, the cost sharing offset amounts related to the expenditures reported on line 1.A. should be reported separately on line 1.B. NOTE: Line items 1.A. - D. above relate to capitated payments on behalf of CHIP recipients in Managed Care Arrangements. Do not breakout out the amounts reported on lines 1.A.- 1.D. in lines 2 - 26 below, as they relate to expenditures for CHIP recipients in Fee-For-Service Plans.

2

Inpatient Hospital

Line 2. Inpatient Hospital Services - Regular Payments..--Use the definition as contained in Part 2 Section 2500.2.E., line 1.A. (Inpatient Hospital Services - Regular Payments) of the State Medicaid Manual.

3

Inpatient Mental Health

Line 3. Inpatient Mental Health Facility Services - Regular Payments..---Use the definition as contained in Part 2 Section 2500.2.E., line 2.A. (Mental Health Facility Services-Regular Payments) of the State Medicaid Manual.

4

Nursing Care Services

Line 4. Nursing Care Services. - (Other than services in an institution for mental health conditions).---Use the definition as contained in Part 2 Section 2500.2.E., line 29 paragraph g., (Other Care Services- nurse midwife services), of the State Medicaid Manual.

5

Physician/Surgical

Line 5. Physician and Surgical Services..--Use the definition as contained in Part 2 Section 2500.2.E., line 5. (Physicians’ Services) of the State Medicaid Manual.

6

Outpatient Hospital

Line 6. Outpatient Hospital Services. .-:-Use the definition as contained in Part 2 Section 2500.2.E., line 6. (Outpatient Hospital Services) of the State Medicaid Manual for services related to non-mental health facilities which are reported on line 7. below.

7

Outpatient Mental Health

Line 7. Outpatient Mental Health Facility Services. .---Use the definition as contained in Part 2 Section 2500.2.E., line 6 (Outpatient Hospital Services) of the State Medicaid Manual for services related to mental health facilities only.

8

Prescribed Drugs

Line 8. Prescribed Drugs..--Use the definition as contained in Part 2 Section 2500.2.E., line 7. (Prescribed Drugs) of the State Medicaid Manual.

8A

Drug Rebate

8.A.1. Drug Rebate Offset.--This is a refund from the manufacturer for single source drugs, innovator multiple source drugs, and non-innovator multiple source drugs.

9

Dental Services

Line 9. Dental Services..--Use the definition as contained in Part 2 Section 2500.2.E., lines 8 (Dental Services) and 29 paragraph e. (Other Care Services-Dentures) of the State Medicaid Manual

10

Vision Services

Line 10. Vision Services...--Use the definition as contained in Part 2 Section 2500.2.E., line 29. paragraph e., (Other Care Services-eyeglasses) of the State Medicaid Manual.

11

Other Practitioners

Line 11. Other Practitioners' Services..---Use the definition as contained in Part 2 Section 2500.2.E., lines 9. (Other Practitioners’ Services) and 29 paragraph f. (Other Care Services--diagnostic, screening, rehabilitative, and preventive services) of the State Medicaid Manual.

12

Clinic Services

Line 12. Clinic Services..--Use the definition as contained in Part 2 Section 2500.2.E., lines 10.(Clinic Services) and 16. (Rural Health Clinic Services) of the State Medicaid Manual.

13

Therapy Services

Line 13. Therapy Services..---Use the definition as contained in Part 2 Section 2500.2.E., line 29 (Other Care Services) paragraphs b. (Physical Therapy), c. (Occupational Therapy), and d. (Services for individuals with speech, hearing, and language disorders) of the State Medicaid Manual.

14

Laboratory/Radiological

Line 14. Laboratory And Radiological Services..--Use the definition as contained in Part 2 Section 2500.2.E., line 11. (Laboratory and Radiological Services of the State Medicaid Manual.

15

Medical Equipment

Line 15. Durable and Disposable Medical Equipment.-Use the definition as contained in Part 2 Section 2500.2.E., line 29. paragraph e. (Other Care Services-prosthetic devices) of the State Medicaid Manual

16

Family Planning

Line 16.Family Planning..--On the Form HCFA-64.21 series, the reporting on the family planning line 16 is blocked. This is because of the way family planning services are treated with respect to the available FMAP rate and the application of payments against the States’ FY CHIP allotments (refer to SMM §2500.9.I.1. and .2).

17

Other Pregnancy-related Procedures

Line 17. Other Pregnancy-related Procedures .--Use the definition as contained in Part 2 Section 2500.2.E., line 14. of the State Medicaid Manual.

18

Screening Services

Line 18. Screening Services..--Use the definition as contained in Part 2 Section 2500.2.E., line 15. (EPSDT Screening Services) of the State Medicaid Manual.

19

Home Health

Line 19. Home Health Services..---Use the definition as contained in Part 2 Section 2500.2.E., line 12. (Home Health Services) of the State Medicaid Manual.

20

Health Services Initiatives

Line 20. Health Services Initiatives States may use funds available under their 10 percent administrative cap to fund Health Service Initiatives (HSIs). An HSI is an activity that protects public health, protects the health of individuals, improves or promotes a state's capacity to deliver public health services, or strengthens the human and material resources necessary to accomplish public health goals relating to improving the health of children, including targeted low-income children and other low-income children. States are not limited in the number of different HSIs they may fund, as long as the state ensures that title XXI funding, within the state's 10 percent limit, is sufficient to continue the proper administration of the CHIP program. If such funds become less than sufficient, the state agrees to redirect title XXI funds from the support of HSIs to the administration of the CHIP program.

21

Home and Community

Line 21. Home and Community-Based Services..---Use the definition as contained in Part 2 Section 2500.2.E., lines 19. (Home and Community-Based Services) and 23. (Personal Care Services) of the State Medicaid Manual.

22

Hospice

Line 22. Hospice Care Services..--Use the definition as contained in Part 2 Section 2500.2.E., line 26. (Hospice Benefits) of the State Medicaid Manual.

23

Medical Transportation

Line 23. Medical Transportation Services..--Use the definition as contained in Part 2 Section 2500.2.E., line 29. paragraph a. (Other Care Services-Transportation) of the State Medicaid Manual.

24

Case Management

Line 24. Case Management Services..--Use the definition as contained in Part 2 Section 2500.2.E., lines 24. (Targeted Case Management Services) and 25 (Primary Care Case Management Services). of the State Medicaid Manual.

25

Translation and Interpretation

Line 25. Translation and Interpretation (Section 201 CHIPRA) Translation may be allowable as an administrative activity if it is not included and paid for as part of a direct medical service and if it is necessary for the proper and efficient administration of the State plan. However, in order for translation to be claimable as administration, it must be provided either by separate units or separate employees performing solely translation activities and it must facilitate access

31

Other Services

Line 31. Other Services

32

Outreach

Outreach Amounts reported on this line should NOT include any amounts reported on Lines 32A or 32B

32A

Increased Outreach and Enrollment of Indians

Line 32.A - Increased Outreach and Enrollment of Indians (Section 202 CHIPRA) )--Enter in Column (a) the total computable amount of expenditures for the Increased Outreach and Enrollment of Indians The MBES will automatically calculate the Federal Share in Columns (b) and (e) at the CHIP rate. These expenditures are NOT applicable to the 10% limit on Outreach and Certain other expenditures. Amounts reported on this line should NOT include any amounts reported on Lines 32 or 32B

32B

Increase outreach and enrollment of children through premium subsidies

Line 32.B - Increase Outreach and Enrollment of children through premium subsidies Amounts reported on this line should NOT include any amounts reported on Lines 32 or 32A

33

Administration

Line 33. Administration. (section 2105(a)(2)(D) of the Act).--Enter the amount of other reasonable costs incurred by the State to administer the plan. NOTE: All of these administrative activities are subject to the 10 percent limit and must be entered in Column(c). See Section 2115 K above for a discussion of administrative costs and Section 2115 J above for a discussion of the 10 percent limit.

34

PERM Administration

Line 34 - PERM Administration - (Section 601 CHIPRA) )--Enter in Column (a) the total computable amount of expenditures for the administration of PERM. The MBES will automatically enter in Columns (b) and (e) 90 percent of the amount reported in Column (a).

35

Citizenship Verification Technology CHIPRA

Line 35. Citizenship Verification Technology- (Section 211 CHIPRA)

35A

CVT Development

Line 35A. CVT Development: (Section 211 CHIPRA)--Enter in Column (a) the total computable amount of expenditures for the design, development, or installation of Citizenship Verification technology. The MBES will automatically enter in Columns (b) and (e) 90 percent of the amount reported in Column (a).

35B

CVT Operation

Line 35B. CVT Operation (Section 211 CHIPRA)--Enter in Column (a) the total computable amount of expenditures for the operation of Citizenship Verification technology. The MBES will automatically enter in Columns (b) and (e) 75 percent of the amount reported in Column (a).

48

Balance

Line 48 - Balance.--The CBES will generate and enter the subtotal of Lines 1 through 47 for Columns (a)-(e).

49

Less: Collections

Line 49 - Collections.--Enter the total computable amount of refunds or collections attributable to the CHIP program, e.g., refunds for erroneous payments to providers, tort collections, any cost sharing amounts not included in Lines 1B or 1D, or any other refunds that offset allowable expenditures.

50

Total

Line 50. Total



Appendix K: Crosswalk of T-MSIS to MSIS Type of Service Values

Old Code Definitions

MSIS Old Valid Values

 

T-MSIS 1.0 Valid Values

New Code Definitions

 

T-MSIS

1.1 Valid Values

New Code Definitions

Inpatient Hospital

01

 

020

Inpatient Hospital Services (General)

 

001

Inpatient hospital services, other than services in an institution for mental diseases







090

Critical access hospital services - IP




022

Inpatient hospital services (physical rehabilitation







017

Anesthesia services







037

Skilled care – hospital residing


091

Skilled care – hospital residing




038

Exceptional care – hospital residing


092

Exceptional care – hospital residing




039

DD/MI non-acute care – hospital residing


093

Non-acute care – hospital residing

Mental Health Hospital Services for the Aged

02

 

107

Mental Health Hospital Services for the Aged

 

044

Inpatient hospital services for individuals age 65 or older in institutions for mental diseases







045

Nursing facility services for individuals age 65 or older in institutions for mental diseases

Disproportionate Share Hospital (DSH)

03

 

123

Disproportionate Share Hospital (DSH)

 

123

Disproportionate Share Hospital (DSH)

Inpatient Psychiatric Facility Services for Individuals Age 21 Years and Under

04

 

106

Inpatient Psychiatric Facility Services for Individuals Age 21 Years and Under

 

048

Inpatient psychiatric services for individuals under age 21

ICF Services for Individuals with Mental Health Condition

05

 

105

ICF Services for Individuals with Mental Health Condition

 

046

Intermediate care facility (ICF/IIDICF/IID) services

NF'S - All Other

07

 

108

NF'S - All Other

 

009

Nursing facility services for individuals age 21 or older (other than services in an institution for mental disease)







047

Nursing facility services, other than in institutions for mental diseases

Physicians

08

 

112

Physicians

 

012

Physicians’ services




017

Anesthesia services




Dental

09

 

002

Dental Services

 

029

Dental Services

Other Practitioners

10

 

109

Other Practitioners

 

015

Medical or other remedial care or services, other than physicians' services, provided by licensed practitioners within the scope of practice as defined under State law

Outpatient Hospital

11

 

024

Outpatient Services (General)

 

002

Outpatient hospital services







061

Critical access hospital services - OT

 

 

 

025

Outpatient Services (ESRD)

 


Clinic

12

 

026

General Clinic Services

 

028

Clinic services




030

Healthy Kids Services


041

Preventive Services

 

 

 

027

Psychiatric Clinic Services (Type 'A')

 



 

 

 

028

Psychiatric Clinic Services (Type 'B')

 



 

 

 

029

Clinic Services (Physical Rehabilitation)

 






035

Alcohol & Substance Abuse Rehab


014

Outpatient Substance Abuse Treatment Services

Home Health

13

 

124

Home Health

 

016

Home health services - Nursing services







017

Home health services - Home health aide services







018

Home health services - Medical supplies, equipment, and appliances suitable for use in the home







019

Home health services - Physical therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services







020

Home health services - Occupational therapy provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services







021

Home health services - Speech pathology and audiology services provided by a home health agency or by a facility licensed by the State to provide medical rehabilitation services

Lab and X-Ray

15

 

043

Clinical Laboratory Services

 

005

Professional laboratory services provided by a referral laboratory in an office or similar facility other than a hospital outpatient department or clinic







006

Technical laboratory services provided by a referral laboratory in an office or similar facility other than a hospital outpatient department or clinic

 

 

 

044

Portable X-Ray Services

 

007

Professional radiological services provided by a referral x-ray facility in an office or similar facility other than a hospital outpatient department or clinic







008

Technical radiological services provided by a referral x-ray facility in an office or similar facility other than a hospital outpatient department or clinic

Prescribed Drugs

16

 

113

Prescribed Drugs

 

033

Prescribed drugs

 

 

 

135

Pharmacy OTC

 

034

Over-the-counter medications.





041


Medical Equipment/Prosthetic devices


036

Medical Equipment/Prosthetic devices









Other Services

19


060

Home Care


064

HCBS - Home health aide services



 

110

Other Services

 

035

Dentures







037

Eyeglasses







062

HCBS - Case management services







063

HCBS - Homemaker services







065

HCBS - Personal care services







066

HCBS - Adult day health services







067

HCBS - Habilitation services




063

Respite Care


068

HCBS - Respite care services







069

HCBS - Day treatment or other partial hospitalization services, psychosocial rehabilitation services and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness







073

HCBS - Other services requested by the agency and approved by CMS as cost effective and necessary to avoid institutionalization







074

HCBS - Expanded habilitation services - Prevocational services







075

HCBS - Expanded habilitation services - Educational services







076

HCBS - Expanded habilitation services - Supported employment services, which facilitate paid employment







077

HCBS-65-plus - Case management services







078

HCBS-65-plus - Homemaker services







079

HCBS-65-plus - Home health aide services







080

HCBS-65-plus - Personal care services







081

HCBS-65-plus - Adult day health services




063

Respite Care


082

HCBS-65-plus - Respite care services







083

HCBS-65-plus - Other medical and social services requested by the Medicaid agency and approved by CMS, which will contribute to the health and well-being of individuals and their ability to reside in a community-based care setting

Capitated Payment s to HMO, HIO or PACE Plan

20

 

119

Capitated Payment s to HMO, HIO or PACE Plan

 

119

Capitated payments to HMOs, HIOs, or PACE plans

Capitated Payments to Prepaid Health Plans (PHPs)

21

 

122

Capitated Payments to Prepaid Health Plans (PHPs)

 

122

Capitated payments to prepaid health plans (PHPs)

Capitated Payments for Primary Care Case Management (PCCM)

22

 

120

Capitated Payments for Primary Care Case Management (PCCM)

 

120

Capitated payments for primary care case management (PCCM)

Capitated Payments for Private Health Insurance

23

 

121

Capitated Payments for Private Health Insurance

 

121

Capitated payments for private health insurance

Sterilizations

24

 

116

Sterilizations

 

084

Sterilizations

Other Pregnancy-related Procedures

25

 

100

Other Pregnancy-related Procedures

 

086

Other Pregnancy-related Procedures

Transportation Services

26

 

118

Transportation Services

 

056

Transportation services

Personal Care Services

30

 

111

Personal Care Services

 

051

Personal care services

Targeted Case Management

31

 

117

Targeted Case Management

 

053

Targeted case management services




068

Targeted Care Management




Rehabilitation Services

33

 

114

Rehabilitation Services

 

043

Rehabilitative services

PT, OT, Speech, Hearing Language

34

 

011

Physical Therapy Services

 

030

Physical therapy services (when not provided under home health services)

 

 

 

012

Occupational Therapy Services

 

031

Occupational therapy services (when not provided under home health services)

 

 

 

013

Speech Therapy/Pathology Services

 

032

Speech, hearing, and language disorders services (when not provided under home health services)

 

 

 

014

Audiology Services

 

032

Speech, hearing, and language disorders services (when not provided under home health services)

Hospice Benefits

35

 

104

Hospice Benefits

 

087

Hospice Benefits

Nurse Midwife Services

36

 

018

Midwife Services

 

025

Nurse-midwife service

Nurse Practitioner Services

37

 

057

Nurse Practitioner Services

 

026

Nurse practitioner services




010

Nursing Services




Private Duty Nursing

38

 

129

Private Duty Nursing

 

022

Private duty nursing services

Religious Non-Medical Health Care Institutions

39

 

131

Religious Non-Medical Health Care Institutions

 

058

Services furnished in a religious nonmedical health care institution

Supplemental Payment - Inpatient

40

 

132

Supplemental Payment - Inpatient

 

132

Supplemental payment – inpatient

Supplemental Payment - Nursing

41

 

133

Supplemental Payment - Nursing

 

133

Supplemental payment – nursing

Supplemental Payment - Outpatient

42

 

134

Supplemental Payment - Outpatient

 

134

Supplemental payment – outpatient

Durable Medical Equipment and Supplies (including emergency response systems and home modifications)

51

 

103

Durable Medical Equipment and Supplies (including emergency response systems and home modifications)

 

018

Home health services - Medical supplies, equipment, and appliances suitable for use in the home

Residential Care

52


115

Residential Care


115

Residential Care

Psychiatric services (excluding adult day care)

53

 

130

Psychiatric services (excluding adult day care)

 

048

Inpatient psychiatric services for individuals under age 21

Adult Day Care

54

 

101

Adult Day Care

 

066

HCBS - Adult day health services







069

HCBS - Day treatment or other partial hospitalization services, psychosocial rehabilitation services and clinic services (whether or not furnished in a facility) for individuals with chronic mental illness

Indian Health Service (IHS) - Family Plan

60

 

127

Indian Health Service (IHS) - Family Plan

 

011

Family planning services and supplies for individuals of child-bearing age

Indian Health Service (IHS) - BCC

61

 

125

Indian Health Service (IHS) - BCC

 

004

Other ambulatory services furnished by a rural health clinic

Indian Health Service (IHS) - BIP

62

 

126

Indian Health Service (IHS) - BIP

 

004

Other ambulatory services furnished by a rural health clinic





Appendix L: Crosswalk of Washington Publishing Company Provider Taxonomy Codes to Provider Facility Type Categories

Source:

http://www.wpc-edi.com/reference/



Provider Taxonomy Code

Provider Taxonomy Description

Provider Facility Type Code

Provider Facility Type Description

193200000X

Unspecified Multi-Specialty Group

100000000

Individuals or Groups (of Individuals)

193400000X

Unspecified Single Specialty Group

100000000

Individuals or Groups (of Individuals)

207K00000X

Allergy & Immunology

100000000

Individuals or Groups (of Individuals)

207KA0200X

Allergy

100000000

Individuals or Groups (of Individuals)

207KI0005X

Clinical & Laboratory Immunology

100000000

Individuals or Groups (of Individuals)

207L00000X

Anesthesiology

100000000

Individuals or Groups (of Individuals)

207LA0401X

Addiction Medicine

100000000

Individuals or Groups (of Individuals)

207LC0200X

Critical Care Medicine

100000000

Individuals or Groups (of Individuals)

207LH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of Individuals)

207LP2900X

Pain Medicine

100000000

Individuals or Groups (of Individuals)

207LP3000X

Pediatric Anesthesiology

100000000

Individuals or Groups (of Individuals)

208U00000X

Clinical Pharmacology

100000000

Individuals or Groups (of Individuals)

208C00000X

Colon & Rectal Surgery

100000000

Individuals or Groups (of Individuals)

207N00000X

Dermatology

100000000

Individuals or Groups (of Individuals)

207NI0002X

Clinical & Laboratory Dermatological Immunology

100000000

Individuals or Groups (of Individuals)

207ND0900X

Dermatopathology

100000000

Individuals or Groups (of Individuals)

207ND0101X

MOHS-Micrographic Surgery

100000000

Individuals or Groups (of Individuals)

207NP0225X

Pediatric Dermatology

100000000

Individuals or Groups (of Individuals)

207NS0135X

Procedural Dermatology

100000000

Individuals or Groups (of Individuals)

204R00000X

Electrodiagnostic Medicine

100000000

Individuals or Groups (of Individuals)

207P00000X

Emergency Medicine

100000000

Individuals or Groups (of Individuals)

207PE0004X

Emergency Medical Services

100000000

Individuals or Groups (of Individuals)

207PH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of Individuals)

207PT0002X

Medical Toxicology

100000000

Individuals or Groups (of Individuals)

207PP0204X

Pediatric Emergency Medicine

100000000

Individuals or Groups (of Individuals)

207PS0010X

Sports Medicine

100000000

Individuals or Groups (of Individuals)

207PE0005X

Undersea and Hyperbaric Medicine

100000000

Individuals or Groups (of Individuals)

207Q00000X

Family Medicine

100000000

Individuals or Groups (of Individuals)

207QA0401X

Addiction Medicine

100000000

Individuals or Groups (of Individuals)

207QA0000X

Adolescent Medicine

100000000

Individuals or Groups (of Individuals)

207QA0505X

Adult Medicine

100000000

Individuals or Groups (of Individuals)

207QB0002X

Bariatric Medicine

100000000

Individuals or Groups (of Individuals)

207QG0300X

Geriatric Medicine

100000000

Individuals or Groups (of Individuals)

207QH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of Individuals)

207QS1201X

Sleep Medicine

100000000

Individuals or Groups (of Individuals)

207QS0010X

Sports Medicine

100000000

Individuals or Groups (of Individuals)

208D00000X

General Practice

100000000

Individuals or Groups (of Individuals)

208M00000X

Hospitalist

100000000

Individuals or Groups (of Individuals)

202C00000X

Independent Medical Examiner

100000000

Individuals or Groups (of Individuals)

207R00000X

Internal Medicine

100000000

Individuals or Groups (of Individuals)

207RA0401X

Addiction Medicine

100000000

Individuals or Groups (of Individuals)

207RA0000X

Adolescent Medicine

100000000

Individuals or Groups (of Individuals)

207RA0201X

Allergy & Immunology

100000000

Individuals or Groups (of Individuals)

207RB0002X

Bariatric Medicine

100000000

Individuals or Groups (of Individuals)

207RC0000X

Cardiovascular Disease

100000000

Individuals or Groups (of Individuals)

207RI0001X

Clinical & Laboratory Immunology

100000000

Individuals or Groups (of Individuals)

207RC0001X

Clinical Cardiac Electrophysiology

100000000

Individuals or Groups (of Individuals)

207RC0200X

Critical Care Medicine

100000000

Individuals or Groups (of Individuals)

207RE0101X

Endocrinology, Diabetes & Metabolism

100000000

Individuals or Groups (of Individuals)

207RG0100X

Gastroenterology

100000000

Individuals or Groups (of Individuals)

207RG0300X

Geriatric Medicine

100000000

Individuals or Groups (of Individuals)

207RH0000X

Hematology

100000000

Individuals or Groups (of Individuals)

207RH0003X

Hematology & Oncology

100000000

Individuals or Groups (of Individuals)

207RI0008X

Hepatology

100000000

Individuals or Groups (of Individuals)

207RH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of Individuals)

207RH0005X

Hypertension Specialist

100000000

Individuals or Groups (of Individuals)

207RI0200X

Infectious Disease

100000000

Individuals or Groups (of Individuals)

207RI0011X

Interventional Cardiology

100000000

Individuals or Groups (of Individuals)

207RM1200X

Magnetic Resonance Imaging (MRI)

100000000

Individuals or Groups (of Individuals)

207RX0202X

Medical Oncology

100000000

Individuals or Groups (of Individuals)

207RN0300X

Nephrology

100000000

Individuals or Groups (of Individuals)

207RP1001X

Pulmonary Disease

100000000

Individuals or Groups (of Individuals)

207RR0500X

Rheumatology

100000000

Individuals or Groups (of Individuals)

207RS0012X

Sleep Medicine

100000000

Individuals or Groups (of Individuals)

207RS0010X

Sports Medicine

100000000

Individuals or Groups (of Individuals)

207RT0003X

Transplant Hepatology

100000000

Individuals or Groups (of Individuals)

209800000X

Legal Medicine

100000000

Individuals or Groups (of Individuals)

207SG0202X

Clinical Biochemical Genetics

100000000

Individuals or Groups (of Individuals)

207SC0300X

Clinical Cytogenetic

100000000

Individuals or Groups (of Individuals)

207SG0201X

Clinical Genetics (M.D.)

100000000

Individuals or Groups (of Individuals)

207SG0203X

Clinical Molecular Genetics

100000000

Individuals or Groups (of Individuals)

207SM0001X

Molecular Genetic Pathology

100000000

Individuals or Groups (of Individuals)

207SG0205X

Ph.D. Medical Genetics

100000000

Individuals or Groups (of Individuals)

207T00000X

Neurological Surgery

100000000

Individuals or Groups (of Individuals)

207U00000X

Nuclear Medicine

100000000

Individuals or Groups (of Individuals)

207UN0903X

In Vivo & In Vitro Nuclear Medicine

100000000

Individuals or Groups (of Individuals)

207UN0901X

Nuclear Cardiology

100000000

Individuals or Groups (of Individuals)

207UN0902X

Nuclear Imaging & Therapy

100000000

Individuals or Groups (of Individuals)

204D00000X

Neuromusculoskeletal Medicine & OMM

100000000

Individuals or Groups (of Individuals)

204C00000X

Neuromusculoskeletal Medicine, Sports Medicine

100000000

Individuals or Groups (of Individuals)

207V00000X

Obstetrics & Gynecology

100000000

Individuals or Groups (of Individuals)

207VB0002X

Bariatric Medicine

100000000

Individuals or Groups (of Individuals)

207VC0200X

Critical Care Medicine

100000000

Individuals or Groups (of Individuals)

207VF0040X

Female Pelvic Medicine and Reconstructive Surgery

100000000

Individuals or Groups (of Individuals)

207VX0201X

Gynecologic Oncology

100000000

Individuals or Groups (of Individuals)

207VG0400X

Gynecology

100000000

Individuals or Groups (of Individuals)

207VH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of Individuals)

207VM0101X

Maternal & Fetal Medicine

100000000

Individuals or Groups (of Individuals)

207VX0000X

Obstetrics

100000000

Individuals or Groups (of Individuals)

207VE0102X

Reproductive Endocrinology

100000000

Individuals or Groups (of Individuals)

207W00000X

Ophthalmology

100000000

Individuals or Groups (of Individuals)

204E00000X

Oral & Maxillofacial Surgery

100000000

Individuals or Groups (of Individuals)

207X00000X

Orthopaedic Surgery

100000000

Individuals or Groups (of Individuals)

207XS0114X

Adult Reconstructive Orthopaedic Surgery

100000000

Individuals or Groups (of Individuals)

207XX0004X

Foot and Ankle Surgery

100000000

Individuals or Groups (of Individuals)

207XS0106X

Hand Surgery

100000000

Individuals or Groups (of Individuals)

207XS0117X

Orthopaedic Surgery of the Spine

100000000

Individuals or Groups (of Individuals)

207XX0801X

Orthopaedic Trauma

100000000

Individuals or Groups (of Individuals)

207XP3100X

Pediatric Orthopaedic Surgery

100000000

Individuals or Groups (of Individuals)

207XX0005X

Sports Medicine

100000000

Individuals or Groups (of Individuals)

207Y00000X

Otolaryngology

100000000

Individuals or Groups (of Individuals)

207YS0123X

Facial Plastic Surgery

100000000

Individuals or Groups (of Individuals)

207YX0602X

Otolaryngic Allergy

100000000

Individuals or Groups (of Individuals)

207YX0905X

Otolaryngology/Facial Plastic Surgery

100000000

Individuals or Groups (of Individuals)

207YX0901X

Otology & Neurotology

100000000

Individuals or Groups (of Individuals)

207YP0228X

Pediatric Otolaryngology

100000000

Individuals or Groups (of Individuals)

207YX0007X

Plastic Surgery within the Head & Neck

100000000

Individuals or Groups (of Individuals)

207YS0012X

Sleep Medicine

100000000

Individuals or Groups (of Individuals)

207ZP0101X

Anatomic Pathology

100000000

Individuals or Groups (of Individuals)

207ZP0102X

Anatomic Pathology & Clinical Pathology

100000000

Individuals or Groups (of Individuals)

207ZB0001X

Blood Banking & Transfusion Medicine

100000000

Individuals or Groups (of Individuals)

207ZP0104X

Chemical Pathology

100000000

Individuals or Groups (of Individuals)

207ZC0006X

Clinical Pathology

100000000

Individuals or Groups (of Individuals)

207ZP0105X

Clinical Pathology/Laboratory Medicine

100000000

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SNF/Subacute Care

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Rehabilitation, Blind

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Audiologist-Hearing Aid Fitter

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Specialist/Technologist

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Audiology Assistant

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Speech-Language Assistant

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Speech-Language Pathologist

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Student in an Organized Health Care Education/Training Program

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Perfusionist

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Radiologic Technologist

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Bone Densitometry

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Cardiac-Interventional Technology

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Cardiovascular-Interventional Technology

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Computed Tomography

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Nuclear Medicine Technology

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Quality Management

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Cardiovascular Invasive Specialist

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Coding Specialist, Hospital Based

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Coding Specialist, Physician Office Based

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Biomedical Engineering

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Biomedical Photographer

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Biostatistician

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Certified First Assistant

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EEG

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Electroneurodiagnostic

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Graphics Methods

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Blood Banking

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Hemapheresis Practitioner

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Microbiology

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Biomedical Engineering

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Darkroom

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EEG

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Renal Dialysis

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Veterinary

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Clinical Laboratory Director, Non-physician

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Histology

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Medical Laboratory

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Phlebotomy

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Local Education Agency (LEA)

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Non-Individual - Agencies

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Case Management

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Day Training, Developmentally Disabled Services

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Early Intervention Provider Agency

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Foster Care Agency

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Home Infusion

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Program of All-Inclusive Care for the Elderly (PACE) Provider Organization

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Public Health or Welfare

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Corporate Health

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Critical Access Hospital

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Family Planning, Non-Surgical

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Federally Qualified Health Center (FQHC)

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Genetics

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Health Service

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Hearing and Speech

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Lithotripsy

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Medically Fragile Infants and Children Day Care

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Mental Health (Including Community Mental Health Center)

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Methadone

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Migrant Health

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Military Ambulatory Procedure Visits Operational (Transportable)

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Military and U.S. Coast Guard Ambulatory Procedure

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Military Outpatient Operational (Transportable) Component

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Military/U.S. Coast Guard Outpatient

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Multi-Specialty

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Occupational Medicine

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Oncology

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Oncology, Radiation

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Ophthalmologic Surgery

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Pain

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Physical Therapy

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Podiatric

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Non-Individual - Ambulatory Health Care Facilities

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Primary Care

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Non-Individual - Ambulatory Health Care Facilities

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Prison Health

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Public Health, Federal

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Non-Individual - Ambulatory Health Care Facilities

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Public Health, State or Local

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Radiology

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Radiology, Mammography

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Radiology, Mobile

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Radiology, Mobile Mammography

260000000

Non-Individual - Ambulatory Health Care Facilities

261QR0800X

Recovery Care

260000000

Non-Individual - Ambulatory Health Care Facilities

261QR0400X

Rehabilitation

260000000

Non-Individual - Ambulatory Health Care Facilities

261QR0404X

Rehabilitation, Cardiac Facilities

260000000

Non-Individual - Ambulatory Health Care Facilities

261QR0401X

Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)

260000000

Non-Individual - Ambulatory Health Care Facilities

261QR0405X

Rehabilitation, Substance Use Disorder

260000000

Non-Individual - Ambulatory Health Care Facilities

261QR1100X

Research

260000000

Non-Individual - Ambulatory Health Care Facilities

261QR1300X

Rural Health

260000000

Non-Individual - Ambulatory Health Care Facilities

261QS1200X

Sleep Disorder Diagnostic

260000000

Non-Individual - Ambulatory Health Care Facilities

261QS1000X

Student Health

260000000

Non-Individual - Ambulatory Health Care Facilities

261QU0200X

Urgent Care

260000000

Non-Individual - Ambulatory Health Care Facilities

261QV0200X

VA

260000000

Non-Individual - Ambulatory Health Care Facilities

273100000X

Epilepsy Unit

270000000

Non-Individual - Hospital Units

275N00000X

Medicare Defined Swing Bed Unit

270000000

Non-Individual - Hospital Units

273R00000X

Psychiatric Unit

270000000

Non-Individual - Hospital Units

273Y00000X

Rehabilitation Unit

270000000

Non-Individual - Hospital Units

276400000X

Rehabilitation, Substance Use Disorder Unit

270000000

Non-Individual - Hospital Units

287300000X

Christian Science Sanitorium

280000000

Non-Individual - Hospitals

281P00000X

Chronic Disease Hospital

280000000

Non-Individual - Hospitals

281PC2000X

Children

280000000

Non-Individual - Hospitals

282N00000X

General Acute Care Hospital

280000000

Non-Individual - Hospitals

282NC2000X

Children

280000000

Non-Individual - Hospitals

282NC0060X

Critical Access

280000000

Non-Individual - Hospitals

282NR1301X

Rural

280000000

Non-Individual - Hospitals

282NW0100X

Women

280000000

Non-Individual - Hospitals

282E00000X

Long Term Care Hospital

280000000

Non-Individual - Hospitals

286500000X

Military Hospital

280000000

Non-Individual - Hospitals

2865C1500X

Community Health

280000000

Non-Individual - Hospitals

2865M2000X

Military General Acute Care Hospital

280000000

Non-Individual - Hospitals

2865X1600X

Military General Acute Care Hospital. Operational (Transportable)

280000000

Non-Individual - Hospitals

283Q00000X

Psychiatric Hospital

280000000

Non-Individual - Hospitals

283X00000X

Rehabilitation Hospital

280000000

Non-Individual - Hospitals

283XC2000X

Children

280000000

Non-Individual - Hospitals

282J00000X

Religious Nonmedical Health Care Institution

280000000

Non-Individual - Hospitals

284300000X

Special Hospital

280000000

Non-Individual - Hospitals

291U00000X

Clinical Medical Laboratory

290000000

Non-Individual - Laboratories

292200000X

Dental Laboratory

290000000

Non-Individual - Laboratories

291900000X

Military Clinical Medical Laboratory

290000000

Non-Individual - Laboratories

293D00000X

Physiological Laboratory

290000000

Non-Individual - Laboratories

302F00000X

Exclusive Provider Organization

300000000

Non-Individual - Managed Care Organizations

302R00000X

Health Maintenance Organization

300000000

Non-Individual - Managed Care Organizations

305S00000X

Point of Service

300000000

Non-Individual - Managed Care Organizations

305R00000X

Preferred Provider Organization

300000000

Non-Individual - Managed Care Organizations

311500000X

Alzheimer Center (Dementia Center)

310000000

Non-Individual - Nursing & Custodial Care Facilities

310400000X

Assisted Living Facility

310000000

Non-Individual - Nursing & Custodial Care Facilities

3104A0630X

Assisted Living, Behavioral Disturbances

310000000

Non-Individual - Nursing & Custodial Care Facilities

3104A0625X

Assisted Living, Mental Illness

310000000

Non-Individual - Nursing & Custodial Care Facilities

317400000X

Christian Science Facility

310000000

Non-Individual - Nursing & Custodial Care Facilities

311Z00000X

Custodial Care Facility

310000000

Non-Individual - Nursing & Custodial Care Facilities

311ZA0620X

Adult Care Home

310000000

Non-Individual - Nursing & Custodial Care Facilities

315D00000X

Hospice, Inpatient

310000000

Non-Individual - Nursing & Custodial Care Facilities

310500000X

Intermediate Care Facility, Mental Illness

310000000

Non-Individual - Nursing & Custodial Care Facilities

315P00000X

Intermediate Care Facility, Mentally Retarded

310000000

Non-Individual - Nursing & Custodial Care Facilities

313M00000X

Nursing Facility/Intermediate Care Facility

310000000

Non-Individual - Nursing & Custodial Care Facilities

314000000X

Skilled Nursing Facility

310000000

Non-Individual - Nursing & Custodial Care Facilities

3140N1450X

Nursing Care, Pediatric

310000000

Non-Individual - Nursing & Custodial Care Facilities

177F00000X

Lodging

170000000

Non-Individual - Other Service Providers

174200000X

Meals

170000000

Non-Individual - Other Service Providers

320800000X

Community Based Residential Treatment Facility, Mental Illness

320000000

Non-Individual - Residential Treatment Facilities

320900000X

Community Based Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities

320000000

Non-Individual - Residential Treatment Facilities

323P00000X

Psychiatric Residential Treatment Facility

320000000

Non-Individual - Residential Treatment Facilities

322D00000X

Residential Treatment Facility, Emotionally Disturbed Children

320000000

Non-Individual - Residential Treatment Facilities

320600000X

Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities

320000000

Non-Individual - Residential Treatment Facilities

320700000X

Residential Treatment Facility, Physical Disabilities

320000000

Non-Individual - Residential Treatment Facilities

324500000X

Substance Abuse Rehabilitation Facility

320000000

Non-Individual - Residential Treatment Facilities

3245S0500X

Substance Abuse Treatment, Children

320000000

Non-Individual - Residential Treatment Facilities

385H00000X

Respite Care

380000000

Non-Individual - Respite Care Facility

385HR2050X

Respite Care Camp

380000000

Non-Individual - Respite Care Facility

385HR2055X

Respite Care, Mental Illness, Child

380000000

Non-Individual - Respite Care Facility

385HR2060X

Respite Care, Mental Retardation and/or Developmental Disabilities

380000000

Non-Individual - Respite Care Facility

385HR2065X

Respite Care, Physical Disabilities, Child

380000000

Non-Individual - Respite Care Facility

331L00000X

Blood Bank

330000000

Non-Individual - Suppliers

332100000X

Department of Veterans Affairs (VA) Pharmacy

330000000

Non-Individual - Suppliers

332B00000X

Durable Medical Equipment & Medical Supplies

330000000

Non-Individual - Suppliers

332BC3200X

Customized Equipment

330000000

Non-Individual - Suppliers

332BD1200X

Dialysis Equipment & Supplies

330000000

Non-Individual - Suppliers

332BN1400X

Nursing Facility Supplies

330000000

Non-Individual - Suppliers

332BX2000X

Oxygen Equipment & Supplies

330000000

Non-Individual - Suppliers

332BP3500X

Parenteral & Enteral Nutrition

330000000

Non-Individual - Suppliers

333300000X

Emergency Response System Companies

330000000

Non-Individual - Suppliers

332G00000X

Eye Bank

330000000

Non-Individual - Suppliers

332H00000X

Eyewear Supplier (Equipment, not the service)

330000000

Non-Individual - Suppliers

332S00000X

Hearing Aid Equipment

330000000

Non-Individual - Suppliers

332U00000X

Home Delivered Meals

330000000

Non-Individual - Suppliers

332800000X

Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy

330000000

Non-Individual - Suppliers

335G00000X

Medical Foods Supplier

330000000

Non-Individual - Suppliers

332000000X

Military/U.S. Coast Guard Pharmacy

330000000

Non-Individual - Suppliers

332900000X

Non-Pharmacy Dispensing Site

330000000

Non-Individual - Suppliers

335U00000X

Organ Procurement Organization

330000000

Non-Individual - Suppliers

333600000X

Pharmacy

330000000

Non-Individual - Suppliers

3336C0002X

Clinic Pharmacy

330000000

Non-Individual - Suppliers

3336C0003X

Community/Retail Pharmacy

330000000

Non-Individual - Suppliers

3336C0004X

Compounding Pharmacy

330000000

Non-Individual - Suppliers

3336H0001X

Home Infusion Therapy Pharmacy

330000000

Non-Individual - Suppliers

3336I0012X

Institutional Pharmacy

330000000

Non-Individual - Suppliers

3336L0003X

Long Term Care Pharmacy

330000000

Non-Individual - Suppliers

3336M0002X

Mail Order Pharmacy

330000000

Non-Individual - Suppliers

3336M0003X

Managed Care Organization Pharmacy

330000000

Non-Individual - Suppliers

3336N0007X

Nuclear Pharmacy

330000000

Non-Individual - Suppliers

3336S0011X

Specialty Pharmacy

330000000

Non-Individual - Suppliers

335V00000X

Portable X-Ray Supplier

330000000

Non-Individual - Suppliers

335E00000X

Prosthetic/Orthotic Supplier

330000000

Non-Individual - Suppliers

344800000X

Air Carrier

340000000

Non-Individual - Transportation Services

341600000X

Ambulance

340000000

Non-Individual - Transportation Services

3416A0800X

Air Transport

340000000

Non-Individual - Transportation Services

3416L0300X

Land Transport

340000000

Non-Individual - Transportation Services

3416S0300X

Water Transport

340000000

Non-Individual - Transportation Services

347B00000X

Bus

340000000

Non-Individual - Transportation Services

341800000X

Military/U.S. Coast Guard Transport

340000000

Non-Individual - Transportation Services

3418M1120X

Military or U.S. Coast Guard Ambulance, Air Transport

340000000

Non-Individual - Transportation Services

3418M1110X

Military or U.S. Coast Guard Ambulance, Ground Transport

340000000

Non-Individual - Transportation Services

3418M1130X

Military or U.S. Coast Guard Ambulance, Water Transport

340000000

Non-Individual - Transportation Services

343900000X

Non-emergency Medical Transport (VAN)

340000000

Non-Individual - Transportation Services

347C00000X

Private Vehicle

340000000

Non-Individual - Transportation Services

343800000X

Secured Medical Transport (VAN)

340000000

Non-Individual - Transportation Services

344600000X

Taxi

340000000

Non-Individual - Transportation Services

347D00000X

Train

340000000

Non-Individual - Transportation Services

347E00000X

Transportation Broker

340000000

Non-Individual - Transportation Services





Appendix M: Crosswalk of T-MSIS, MSIS and MMA Duel Eligible Code



Coding requirement on the DUAL-ELIGIBLE-CODE data element

When populating the DUAL-ELIGIBLE-CODE data element, States should ignore the coding requirement regarding Medicare Modernization Act. ("This field should be populated from the same data that were used to populate the State’s submission of the Medicare Modernization Act (“State MMA File”) monthly file to CMS. In other words, the data values from the State MMA File should match this dual eligible data element.")

CMS has already incorporated the MMA valid values into MSIS and carried them forth into T-MSIS, as can be seen in the crosswalk below.

T-MSIS

MSIS

MMA*

00 Eligible is not a Medicare beneficiary

00 Eligible is not a Medicare beneficiary


00 = Not Medicare enrolled for the month


01 Eligible is entitled to Medicare- QMB only

01 Eligible is entitled to Medicare- QMB only


01 = QMB only


02 Eligible is entitled to Medicare- QMB AND Medicaid coverage

02 Eligible is entitled to Medicare- QMB AND Medicaid coverage including RX


02 = QMB and Medicaid coverage including RX


03 Eligible is entitled to Medicare- SLMB only

03 Eligible is entitled to Medicare- SLMB only


3 = SLMB only


04 Eligible is entitled to Medicare- SLMB AND Medicaid coverage

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


04 = SLMB and Medicaid coverage including RX


05 Eligible is entitled to Medicare- QDWI

05 Eligible is entitled to Medicare- QDWI


05 = QDWI


06 Eligible is entitled to Medicare- Qualifying individuals

06 Eligible is entitled to Medicare- Qualifying individuals


06 = Qualifying Individuals


08 Eligible is entitled to Medicare- Other Dual Eligibles (Non QMB, SLMB, QDWI or QI)

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


08 = Other Dual Eligibles (Non-QMB, SLMB, QWDI, or QI)

w/Medicaid coverage including RX


09 Eligible is entitled to Medicare – Other (This code is to be used only with specific CMS approval.)

09 Eligible is entitled to Medicare – Other Dual Eligibles


09 = Other Dual Eligibles but without Medicaid coverage


10 Separate CHIP Eligible is entitled to Medicare

10 Separate CHIP Eligible is entitled to Medicare



99 Eligible's Medicare status is unknown.

99 Eligible's Medicare status is unknown.


99 – Unknown



NA = Non-Medicaid






Appendix N: Coding Specific Data Elements for Claim Files



Clarification of the use of the PROCEDURE-CODE, REVENUE-CODE, HCPCS-RATE, BEGINNING-DATE-OF-SERVICE, and ENDING-DATE-OF-SERVICE fields in the CLAIMOT File.

Because the CLAIMOT file is a catch-all file that includes outpatient facility claims, professional claims and financial transactions, states are having confusion over when to populate the PROCEDURE-CODE, REVENUE-CODE, HCPCS-RATE , BEGINNING-DATE-OF-SERVICE, ENDING-DATE-OF-SERVICE, PROCEDURE-CODE-DATE, PROCEDURE-CODE-FLAG, and PROCEDURE-CODE-MOD-1 thru -4 fields. To assist them we have prepared the following guidelines.

For professional claims:

  • REVENUE-CODE should be 8-filled.

  • HCPCS-RATE should be 8-filled.

  • PROCEDURE-CODE-FLAG should be populated with either “01 (CPT-4), “06” (HCPCS), or “10” through “87” (to indicate other coding schemas).

  • PROCEDURE-CODE should be used to capture the CPT/HCPCS service codes.

  • PROCEDURE-CODE-MOD-1 thru -4 should be populated as needed.

  • BEGINNING-DATE-OF-SERVICE should show the 1st DOS associated with the service code in the PROCEDURE-CODE field.

  • ENDING-DATE-OF-SERVICE should show the last DOS associated with the service code in the PROCEDURE-CODE field.

  • PROCEDURE-CODE-DATE should be 8-filled (This field is superfluous. Beginning-/Ending-Date-of-Service captures the same information and provides more flexibility if the service is provided repeatedly over a period of time.)

For institutional claims for ambulatory care (reported on CLAIMOT file):

  • REVENUE-CODE should be used to capture the services provided.

  • HCPCS-RATE should be used to capture HCPCS details whenever they are needed to support the value in the REVENUE-CODE field. Otherwise, the field should be 8-filled.

  • PROCEDURE-CODE-FLAG should be 8-filled.

  • PROCEDURE-CODE field should be 8-filled.

  • PROCEDURE-CODE-MOD-1 thru -4 should be 8-filled.

  • BEGINNING-DATE-OF-SERVICE should show the 1st DOS associated with the service code in the REVENUE-CODE field.

  • ENDING-DATE-OF-SERVICE should show the last DOS associated with the service code in the REVENUE-CODE field.

  • PROCEDURE-CODE-DATE should be 8-filled (This field is superfluous. Beginning-/Ending-Date-of-Service captures the same information and provides more flexibility if the service is provided repeatedly over a period of time.)

For financial transactions1:

  • REVENUE-CODE field should be 8-filled.

  • HCPCS-RATE should be 8-filled.

  • PROCEDURE-CODE-FLAG should be 8-filled, or populated with “10” through “87” (to indicate other coding schemas if state-specific codes are used).

  • PROCEDURE-CODE field should be 8-filled unless the State has state-specific codes it uses to provide further detail (e.g., codes to split capitation payments into subcategories).

  • PROCEDURE-CODE-MOD-1 thru -4 should be 8-filled.

  • BEGINNING-DATE-OF-SERVICE should show the 1st day of the time period covered by this financial transaction.

  • ENDING-DATE-OF-SERVICE should show the last day of the time period covered by this financial transaction.

  • PROCEDURE-CODE-DATE should be 8-filled (This field is superfluous. Beginning-/Ending-Date-of-Service captures the same information and provides more flexibility if the service is provided repeatedly over a period of time.)



Appendix O: TYPE-OF-SERVICE Hierarchy Table

When a claim has multiple claim lines that could be reported in more than one CLAIMS file, in any combination as represented in columns A, B, C, or D, please report all claim lines in the CLAIMS file type represented by the green highlight in the table below, and report the TYPE-OF-SERVICE as follows:

  1. For claim lines that would have been reported in the MSIS the LT, OT, and RX files,

They are now to be reported in

  • the T-MSIS CLAIMIP file as a complete claim, and

  • code the TYPE-OF-SERVICE to reflect the type of service that represents the entire facility claim (TYPE OF SERVICE CODE of 001, 060, 084, 086, 090, 091, 092, 093, 058, 123, 132, or 135, whichever is most appropriate for CLAIMIP record being reported).


Example – a multi-line claim that was reported in MSIS by the state as separate IP and OT records for the inpatient care, laboratory services, and emergency room services -is now to be reported in T-MSIS entirely as a single inpatient hospital facility claim with every line containing a TYPE-OF-SERVICE – 001.

2. For claim lines that would have been reported in the MSIS OT and RX files,

They are now to be reported in

  • the T-MSIS CLAIMLT file as a complete claim,

  • and code the TYPE-OF-SERVICE to reflect the type of service that represents the entire facility claim (TYPE-OF-SERVICE 009, 044, 045, 046, 047, 048, 050, 059, or 133 whichever is most appropriate for CLAIMLT claim record being reported)

3. For claim lines that would have been reported the RX and OT files in MSIS,

They are now to be reported in

  • the T-MSIS CLAIMRX file as a complete claim billed by a pharmacy or pharmacist (through a pharmacy point-of-sale system),and

  • code the TYPE-OF-SERVICE to reflect the type of service that was provided

Hierarchy Table

to be used when determining which file a claim is to be reported in when the TYPE-OF-SERVICE may be reportable in more than one claims file type.

A


B


C


D


IP

Code TYPE-OF-SERVICE as one of the following for all lines

001, 060, 084, 086, 090, 091, 092, 093, 058, 123, 132, or 135

IP

Code TYPE-OF-SERVICE as one of the following for all lines

001, 058, 123, 132, 135





LT




LT

Code TYPE-OF-SERVICE as one of the following for all lines

009, 044, 045, 046, 047, 048, 050, 059, 133



OT


OT


OT


RX

Code RX TYPE-OF-SERVICE for the RX line 033, 034

RX


RX


RX


OT

Code OT TYPE-OF-SERVICE as the Specific OT TYPE-OF-SERVICE



Appendix P: CMS Guidance Library

Appendix P.01: Submitting Adjustment Claims to TMSIS



Brief Issue Description

There are two ways original claims and their subsequent adjustments can be linked into a claim family – either through all adjustments linking back to the original claim or each subsequent adjustment linking back to the prior claim (i.e. “daisy chain”). Identifying the members of a claim family is necessary in order to evaluate the changes to a claim that occur throughout its life.

Background Discussion

Before delving into CMS’ guidance on how to populate the ICN-ORIG and ICN-ADJ fields, some background discussion is needed on terminology and concepts.

What claim transactions should be submitted to T-MSIS?

Every “final adjudicated version of the claim/encounter” should be submitted to T-MSIS.

A “final adjudicated version of the claim/encounter” is a claim that has completed the adjudication process and the paid/denied process.  The claim and each claim line will have one of the finalized claim status categories listed in Table 1, below.  The actual disposition of the claim can be either “paid” or “denied.”

Table 1: Finalized Claim Status Categories

Code

Finalized Claim Status Category Description

F0

Finalized-The encounter has completed the adjudication cycle and no more action will be taken. (Used on encounter records)

F1

Finalized/Payment-The claim/line has been paid.

F2

Finalized/Denial-The claim/line has been denied.

F3

Finalized/Revised - Adjudication information has been changed.

Both original claims (or encounters) and adjusted claims (or encounters) can be a “final adjudicated version of the claim/encounter.”  Whenever a claim/encounter flows through the adjudication and payment processes (if applicable) and falls into one of the claim status categories in Table 1, the state should send the claim/encounter to T-MSIS. 

If a claim flows through the adjudication and payment processes and falls into one of the finalized claim status categories multiple times within a single T-MSIS reporting period, CMS expects each of these final adjudicated versions of the claim/encounter to be submitted to T-MSIS, not just the one effective on the last day of the reporting period.

If the claim has not been through the final adjudication process or is “pending” (or in “suspense”), the claim should not be sent to T-MSIS until disposition has been settled to one of the finalized claim status categories. Table 2 provides examples and CMS’ expectations.

Table 2: Scenarios for When to Submit Claims

Claim Submission Scenario

CMS’ Expectation

Adjudicated and paid in the same reporting month

CMS expects the claim to be sent to T-MSIS in the reporting month.

Adjudicated in one reporting period, but paid in another reporting month

CMS expects the claim to be sent to T-MSIS in the month that the claim was paid.

Adjudicated and paid in one reporting month, and then re-adjudicated and paid in a subsequent month

The claim should be reported in the month it is paid, regardless of whether it is an original claim or an adjustment. Therefore, in this scenario, CMS expects the original to be reported in month one and the adjustment to be reported in the subsequent month.

Adjudicated and paid, and then re-adjudicated and paid in the same reporting month

In this scenario, if a claim flows through the adjudication and payment processes and falls into one of the claim status categories in Table 1 multiple times within a single T-MSIS reporting period, CMS expects each of these final adjudicated versions of the claim/encounter to be submitted to T-MSIS, not just the one effective on the last day of the reporting period.

Re-adjudicated and paid multiple times in the same reporting month

In this scenario, if a claim flows through the adjudication and payment processes and falls into one of the claim status categories in Table 1 multiple times within a single T-MSIS reporting period, CMS expects each of these final adjudicated versions of the claim/encounter to be submitted to T-MSIS, not just the one effective on the last day of the reporting period.


What is a claim family?

A “claim family” (a.k.a. “adjustment set”)is defined as a set of post-adjudication claim transactions in paid or denied status that relate to the same provider/enrollee/services/dates of service. This grouping of the original claim and all of its subsequent adjustment and/or void claims shows the progression of changes that have occurred since it was first submitted.

How should ADJUSTMENT-IND codes be used?

The table below lists each of the adjustment indicator codes contained in the T-MSIS Data Dictionary version 1.1 and describes when it should be used.

Table 3: Adjustment Indicator Codes and Their Uses

Code

Description of Use

0

Original Claim/Encounter – Indicates this is the first time this family of claim/encounter records has been through the state’s adjudication and payment processes and is a final adjudicated version of the claim/encounter.

1

Void of a prior submission – Use this code when the state wishes to remove a claim/encounter from T-MSIS and not replace it with an adjusted claim/encounter record. These records must have the same claim key data element values as the claim/encounter being voided.

2

Do not use.

3

Do not use.

4

Debit Adjustment (positive supplemental) – Use whenever the claim is an adjusted claim.

5

Credit Gross Adjustment – Use this code to indicate an aggregate-level recoupment of payments made previously to a provider (e.g., for a set of enrollees, claims, etc.) rather than recoupments made on specific claims. Amounts on these claims should be expressed as negative numbers.

6

Debit Gross Adjustment – Use this code to indicate an aggregate-level additional payment to a provider (e.g., for a set of enrollees, claims, etc.) rather than payment made on a specific claim. Amounts on these claims should be expressed as positive numbers.

9

Unknown

Are gross adjustments considered claims/encounters?

While the gross adjustment adjudication indicator codes (values “5” and “6” in Table 3) are reported to T-MSIS in the CLAIM-OT file, they are not technically “claims” or “encounters.” Each of these transactions does not relate to a specific service-provider/enrollee episode of care. Instead, these transactions represent payments made by the state for services rendered to multiple enrollees (as in the case of a provider providing screening services for a group of enrollees), DSH payments, or a recoupment of funds previously dispensed in a debit gross adjustment. Therefore, the concept of “claims family” does not apply. Each of these transactions stands on its own, and does not constitute a subsequent transaction being a replacement of the earlier transaction.

What alternatives are there for tying the members of a claim family together?


The Original ICN Approach

Under this approach, the state assigns an ICN to the initial final adjudicated version of the claim/encounter and records this identifier in the ICN-ORIG field. If adjustment claims subsequently are created, the ICN assigned to the initial final adjudicated version of the claim/encounter is carried forward on every subsequent adjustment claim. Table 4 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are populated when the original ICN approach is used.

Table 4: ICN-ORIG/ICN-ADJ Relationships Under the Original ICN Approach

Event

ADJUDICATION-DATE

ICN-ORIG

ICN-ADJ

ADJUSTMENT-IND

On 5/1/2014, the state completes the adjudication process on the initial version of the claim

5/1/2014

1

-

0

On 7/15/2014, the state completes a claim re-adjudication / adjustment

7/15/2014

1

2

4

On 8/12/2014, the state completes a 2nd claim re-adjudication / adjustment

8/12/2014

1

3

4

On 9/5/2014, the state completes a 3rd claim re-adjudication / adjustment

9/5/2014

1

4

4



The Daisy-Chain ICN Approach

Under this approach, the state records the ICN of the previous final adjudicated version of the claim/encounter in the ICN-ORIG field of the adjustment claim record. If additional adjustment claims are subsequently created, the ICN-ORIG on the new adjustment claim only points back one generation. Table 5 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are populated when the daisy-chain ICN approach is used.

Table 5: ICN-ORIG/ICN-ADJ Relationships Under the Daisy-Chain ICN Approach

Event

ADJUDICATION-DATE

ICN-ORIG

ICN-ADJ

ADJUSTMENT-IND

On 6/1/2014, the state completes the adjudication process on the initial version of the claim

6/1/2014

11

-

0

On 8/15/2014, the state completes a claim re-adjudication/adjustment

8/15/2014

11

12

4

On 9/12/2014, the state completes a 2nd claim re-adjudication/adjustment

9/12/2014

12

13

4

On 10/5/2014, the state completes a 3rd claim re-adjudication/adjustment

10/5/2014

13

14

4


How are ICN-ORIG and ICN-ADJ fields impacted when voids are submitted?

The primary purpose of void transactions (ADJUSTMENT-IND = 1) is to nullify a claim/encounter from T-MSIS when the state does not wish to replace it with an adjusted claim/encounter record. These records must have the same claim key data element values as the claim/encounter being voided. Dollar and quantity fields should be set to zero. The ADJUDICATION-DATE on these records should be set to the date that the state voided the claim. Table 6 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are populated when the state wishes to void a claim.

Table 6: ICN-ORIG/ICN-ADJ – Impact of Voids

Event

ADJUDICATION-DATE

ICN-ORIG

ICN-ADJ

ADJUSTMENT-IND

Dollar Fields

Quantity Fields

On 6/1/2014, the state completes the adjudication process on the initial version of the claim

6/1/2014

51

-

0

100.00

5

On 8/15/2014, the state completes a claim re-adjudication/adjustment

8/15/2014

51

52

4

80.00

5

On 8/19/2014, the claim is voided

8/19/2014

51

52

1

0.00

0



If a state uses a process to record adjustments whereby they void the previous version of the claim and then follow-up with the creation of a new original transaction, and the state can identify that the void and the new original claim are from the same adjudication set, the state should link them together into one claims family using the ICN-ORIG. CMS recognizes that some states may not be able to link a resubmitted claim after a void to the original claim. Table 7 illustrates how CMS is expecting the states to populate the ICN-ORIG/ICN-ADJ fields when the state processes a void/new original when adjusting claims.

Table 7: ICN-ORIG/ICN-ADJ – Keeping the Claim Family Intact When the “Void/New Original” Scenario Occurs

Event

ADJUDICATION-DATE

ICN-ORIG

ICN-ADJ

ADJUSTMENT-IND

Dollar Fields

Quantity Fields

On 6/1/2014, the state completes the adjudication process on the initial version of the claim

6/1/2014

51

-

0

100.00

5

On 8/15/2014, the state completes the adjudication process of a void and associated new original

8/15/2014


51

-

1

0.00

0

8/15/2014


51

52

0

80.00

5

On 9/20/2014, the state completes the adjudication process of a void and associated new original

9/20/2014


51

52

1

0.00

0

9/20/2014


51

53

0

60.00

5



How Adjustment Records will be Applied by CMS

There is an inherent limitation in the way that CMS can interpret what to do with two claim transactions having the same ICN-ORIG and ADJUDICATION-DATE when both transactions are received in a single submission file. The processing rules that T-MSIS will follow are outlined below. It is up to each state to assure that claim transactions are processed in the appropriate sequence. If the rules below do not result in the sequence of transactions that the state desires, it is up to the state to submit transactions in separate files so that the desired sequence is attained.

Rules for inserting claim transactions into the T-MSIS database when two or more claim transactions with the same ICN-ORIG and ADJUDICATION-DATE are in the same submission file

If two or more transactions in an incoming claim file have the same ICN-ORIG and ADJUDICATION-DATE values, T-MSIS will evaluate the ADJUSTMENT-IND values and insert the transactions into the T-MSIS database as follows:

  1. If more than two transactions in the incoming claim file have the same ICN-ORIG and ADJUDICATION-DATE values, then T-MSIS will reject all of the incoming transactions;

  2. If the ADJUSTMENT-IND values of both incoming transactions are the same (but not ‘5’ or ‘6’), then T-MSIS will reject both incoming transactions;

  3. If the ADJUSTMENT-IND values of both incoming transactions are some combination of ‘5’ and ‘6’ and if there is no active existing transaction in the T-MSIS DB, then T-MSIS will insert both incoming transactions into the T-MSIS DB (note, since neither transaction supersedes the other, the order in which they are inserted does not matter);

  4. If the ADJUSTMENT-IND values of both incoming transactions are some combination of ‘5’ and ‘6’ and if there is an active existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘5’ or ‘6’, then T-MSIS will insert both incoming transactions into the T-MSIS DB (note, since neither transaction supersedes the other, the order in which they are inserted does not matter);

  5. If the ADJUSTMENT-IND values of both incoming transactions is a ‘5’ or ‘6’ and if there is an active existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘0’, ‘1’, or ‘4’, then T-MSIS will reject both the incoming transactions;

  6. If the ADJUSTMENT-IND value of one incoming transaction is a ‘5’ or ‘6’ and the ADJUSTMENT-IND of the other transaction is ‘0’, ‘1’, or ‘4’ and if there is an active existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘5’ or ‘6’, then T-MSIS will insert the incoming transaction with ADJUDICATION-IND of ‘5’ or ‘6’ and reject the incoming transaction with ADJUSTMENT-IND value ‘0’, ‘1’, or ‘4’;

  7. If the ADJUSTMENT-IND value of one incoming transaction is a ‘5’ or ‘6’ and the ADJUSTMENT-IND of the other transaction is ‘0’, ‘1’, or ‘4’ and there is an active existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘0’, ‘1’, or ‘4’, then T-MSIS will reject the incoming transaction with ADJUSTMENT-IND value ‘5’ or ‘6’ and evaluate the remaining incoming transaction as follows:

    1. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the active existing transaction is ‘0’, then T-MSIS will reject the incoming transaction;

    2. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the active existing transaction is ‘1’, then T-MSIS will insert the incoming transaction;

    3. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the active existing transaction is ‘4’, then T-MSIS will reject the incoming transaction;

    4. ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the active existing transaction is ‘0’, then T-MSIS will insert the incoming transaction;

    5. ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the active existing transaction is ‘1’, then T-MSIS will reject the incoming transaction;

    6. ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the active existing transaction is ‘4’, then T-MSIS will insert the incoming transaction;

    7. ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the active existing transaction is ‘0’, then T-MSIS will insert the incoming transaction;

    8. ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the active existing transaction is ‘1’, then T-MSIS will insert the incoming transaction;

    9. ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the active existing transaction is ‘4’, then T-MSIS will insert the incoming transaction;

  8. If the ADJUSTMENT-IND value of one incoming transaction is ‘1’ and the ADJUSTMENT-IND of the other transaction is ‘0’ or ‘4’ and the ADJUSTMENT-IND of the active existing transaction in the T-MSIS DB is ‘0’ or ‘4’, then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND = ‘1’ first, and then insert the other transaction;

  9. If the ADJUSTMENT-IND value of one incoming transaction is ‘1’ and the ADJUSTMENT-IND of the other transaction is ‘0’ or ‘4’ and the ADJUSTMENT-IND of the active transaction in the T-MSIS DB is ‘1’, then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND value of ‘0’ or ‘4’ first and then insert the incoming transaction with ADJUSTMENT-IND = ‘1’;

  10. If the ADJUSTMENT-IND value of one incoming transaction is ‘0’ and the ADJUSTMENT-IND value of the other incoming transaction is ‘4’ and there is no active existing transaction in the T-MSIS DB, then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND value of ‘0’ first and then insert the incoming transaction with ADJUSTMENT-IND = ‘4’;

  11. If any other combination of ADJUSTMENT-IND values occurs, then T-MSIS will reject all of the transactions.

CMS Guidance

The state can use either the original ICN approach or the daisy-chain ICN approach to populate the ICN-ORIG field on each member of the claims family. T-MSIS will group claim transactions into claim families as part of the ETL process.



Appendix P.02: Reporting Financial Transactions in T-MSIS - How to populate T-MSIS claim files when reporting non-claim expenditures and recoupments



Brief Issue Description:

The purpose of this guidance document is to clarify the appropriate way to report non-claim expenditure and recoupment transactions, since many of the data elements on the claim records (CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX) do not seem appropriate for these types of transactions.


Background Discussion

Definition of a financial transaction:

For purposes of this guidance, CMS defines a financial transaction as an expenditure transaction or a recoupment of a previously made expenditure that does not flow through the usual claim adjudication/adjustment process.


The cause or effect of this may be that these types of transactions do not contain the same level of detail as other types of transactions in the state’s system. For example, a state might not assign a service code to a capitation claim. Payments made in lump sums, such as Disproportionate Share Hospital (DSH) payments, because they cannot be attributed to a single beneficiary would not contain a beneficiary identifier.


For some states, examples of financial transactions might include capitation payments made to managed care organizations, supplemental payments (i.e., payments that are above a capitation fee or for a sum above a negotiated rate, such as an FQHC additional reimbursement), drug rebates, DSH payments, cost settlements (e.g., program cost reconciliations and settlements, year-end reconciliation of risk pools), aggregate-level payments to providers (e.g., for a set of enrollees, claims, etc.) rather than payments made on a specific claim.


Financial Transactions may be reported on CLAIMIP, CLAIMLT, CLAIMOT, or CLAIMRX depending on the type and circumstances of the financial transaction. “Table 1 – Financial Transactions and the appropriate T-MSIS file for reporting them” identifies which T-MSIS files are appropriate for the various types of financial transactions.


Table 1 – Financial transactions and the appropriate T-MSIS file for reporting them

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

CLAIMOT

CLAIMOT

CLAIMRX

CLAIMIP

CLAIMLT

CLAIMOT

CLAIMRX

CLAIMIP

CLAIMLT

CLAIMOT

CLAIMRX

CLAIMOT

CLAIMOT

CLAIMRX

CLAIMIP

CLAIMLT

CLAIMOT

CLAIMRX

CLAIMIP

CLAIMLT

CLAIMOT

CLAIMRX

CLAIMIP

CLAIMOT

CLAIMIP

CLAIMLT

CLAIMOT

CLAIMRX


Financial transactions can be contained within the same files as fee-for-service claims and encounter records.




CMS Guidance

When and how to populate data elements for financial transactions:

The data elements listed on the following pages are ones that should be populated on financial transactions. Additional verbiage is provided for those data elements that CMS believes need explicit instructions for building T-MSIS files. States should contact their T-MSIS technical assistant or state liaison if they have questions or concerns. Data elements not specifically listed below can be 8-filled.



CLAIM-HEADER-RECORD data elements

  1. RECORD-ID

  2. SUBMITTING-STATE

  3. RECORD-NUMBER

  4. MSIS-IDENTIFICATION-NUM – Populate with beneficiary’s MSIS ID for any beneficiary-specific financial transactions. Otherwise first character of MSIS-IDENTIFICATION-NUM must be “&” to indicate that any characters that might follow do not represent an individual beneficiary’s identifier.

  5. ICN-ORIG – See the document entitled CMS Guidance: T-MSIS Adjustment Claim Records- Populating ICN-ORG and ICN-ADJ Fields posted on 2/18/2014 to the T-MSIS State Support.

  6. ICN-ADJ – See the document entitled CMS Guidance: T-MSIS Adjustment Claim Records- Populating ICN-ORG and ICN-ADJ Fields posted on 2/18/2014 to the T-MSIS State Support

  7. ADJUDICATION-DATE – Date the transaction's approval and payment processes were completed.

  8. CHECK-EFF-DATE – Populate with the date that Medicaid funds were disbursed. (Note: Even though the TOT-MEDICIAD-PAID-AMT field may be set to zero in some circumstances, Medicaid funds were disbursed – and are captured in the SERVICE-TRACKING-PAYMENT-AMT data element.)

  9. ADMISSION-DATE – Populate with the first day of the time period covered by this financial transaction (CLAIMIP and CLAIMLT).

  10. DISCHARGE-DATE – Populate with the last day of the time period covered by this financial transaction (CLAIMIP and CLAIMLT).

  11. BEGINNING-DATE-OF-SERVICE – Populate with the first day of the time period covered by this financial transaction (CLAIMOT).

  12. ENDING-DATE-OF-SERVICE – Populate with the last day of the time period covered by this financial transaction (CLAIMOT).

  13. DATE-PRESCRIBED – Populate with the first day of the time period covered by this financial transaction (CLAIMRX).

  14. PRESCRIPTION-FILL-DATE – Populate with the last day of the time period covered by this financial transaction (CLAIMRX).

  15. WAIVER-TYPE – Populate if applicable and available

  16. WAIVER-ID – Populate if applicable and available

  17. PLAN-ID-NUMBER – Populate with the managed care plan ID for capitation payments made to managed care plans. 8-fill if transaction does not involve a manage care plan.

  18. BILLING-PROV-NPI-NUM – Populate with the provider or entity that the financial transaction was addressed to. 8-fill if transaction involves a manage care plan.

  19. TOT-MEDICIAD-PAID-AMT – If TYPE-OF-CLAIM is 4, D, or X, then set to zero – service tracking payment amount will be populated instead. Otherwise populate with the amount paid to the provider or health plan.

  20. SERVICE-TRACKING-PAYMENT-AMT – If TYPE-OF-CLAIM is 4, D, or X, then populate this with the amount paid, otherwise 0-fill.

  21. TYPE-OF-CLAIM – valid values appropriate for each type of financial transaction are shown in Table 2. (The descriptions of the TYPE-OF-CLAIM values are shown in Table 3. The values appropriate for financial transactions are highlighted in yellow.)


Table 2 – TYPE-OF-CLAIM values for financial transactions

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

2, B, V

5, E, Y

5, E, Y

5, E, Y

4, D, X

4, D, X

4, D, X

4, D, X

4, D, X

4, D, X



Table 3 – Descriptions of TYPE-OF-CLAIM values

Type of Claim Code

Description

Purpose

Medicaid or Medicaid Expansion

Separate CHIP (Title XXI)

Other

1

A

U

Fee-For-Service Claim

Used to report services billed & payments made for specific services rendered to a specific enrollee by a specific provider during a specific period of time. Payment is made only for services actually rendered.

2

B

V

Capitation Payment

Used to report periodic payments made in return for a contractual commitment by the recipient to provide a specified set of services to a specified set of enrollees for a specified period of time. The volume of services actually provided to any given individual is not a factor in the amount of the capitation payment.

3

C

W

Encounter Record

Used to report services provided under a capitated payment arrangement.

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 risk entity has already received a capitated payment from the State.

4

D

X

Service Tracking Claim

Use to report payments made for services rendered to enrollees when the services are not billed and paid at the single enrollee/provider/visit level of detail.

5

E

Y

Supplemental Payment

Used to identify payments that are above a capitation fee or for a sum above a negotiated rate, such as an FQHC additional reimbursement.


  1. SOURCE-LOCATION– valid values appropriate for each type of financial transaction are shown in Table 4.

Table 4 – Descriptions of SOURCE-LOCATION values

Code

Description

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

20

Managed Care Organization (MCO)



  1. SERVICE-TRACKING-TYPE – The appropriate values for financial transactions are shown in Table 5. (The descriptions of the SERVICE-TRACKING-TYPE values are shown in Table 6.)

Table 5 – SERVICE-TRACKING-TYPE values for financial transactions

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

00

00

00

00

03

01

04

05

02

03, 06


Table 6 – Descriptions of SERVICE-TRACKING-TYPE values

Code

Description

00

Not a Service Tracking Claim – Use this code when codes 01 through 06 do not apply

01

Drug Rebate

02

DSH Payment

03

Lump Sum Payment (The "lump sum payment" code identifies payments made for specific services rendered to individual patients, when the state accepts a lump sum bill from a provider that covered similar services delivered to more than one patient (e.g., a group screening for EPSDT).

04

Cost Settlement

05

Supplemental (The "supplemental payment" code identifies payments that are above a capitation fee or sum above a negotiated rate (e.g., FQHC additional reimbursement).)

06

Other



  1. FUNDING-CODE – The appropriate values for financial transactions are shown in Table 7. (The descriptions of the FUNDING-CODE values are shown in Table 8.)

Table 7 – FUNDING-CODE values for financial transactions

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

A or B as appro-priate

A through E

A through I as appro-priate

A through I as appro-priate

A or B as appro-priate

A through E

A through I as appro-priate

A through I as appro-priate

A through I as appro-priate

A through I as appro-priate



Table 8Descriptions of FUNDING-CODE values

Code

Description

A

Medicaid Agency

B

CHIP Agency

C

Mental Health Service Agency

D

Education Agency

E

Child and Family Services Agency

F

County

G

City

H

Providers

I

Other


CLAIM-LINE-RECORD data elements

    1. SUBMITTING-STATE

    2. RECORD-NUMBER

    3. MSIS-IDENTIFICATION-NUM

    4. ICN-ORIG

    5. ICN-ADJ

    6. LINE-NUM-ORIG

    7. LINE-NUM-ADJ

    8. ADJUDICATION-DATE – Date the line-level transaction's approval and payment processes were completed

    9. REVENUE-CODE – 8-fill

    10. PROCEDURE-CODE – 8-fill

    11. NATIONAL-DRUG-CODE – 8-fill

    12. MEDICAID-PAID-AMT – Because there is no data element on the claim line record segment specifically designated to capture service tracking payment amounts at the claim line level, states should populate MEDICAID-PAID-AMT with the amount of Medicaid funds disbursed. For service tracking claims, the sum of the claim line MEDICAID-PAID-AMT values on a claim’s claim line record segments should equal the amount reported in the SERVICE-TRACKING-PAYMENT-AMT data element on the claim’s claim header record segment.

    13. TYPE-OF-SERVICE – The appropriate values for financial transactions are shown in Table 9.


Table 9TYPE-OF-SERVICE values for financial transactions

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

119, 120, 121, 122

131

132, 133, 134, 135

Any TOS except 119, 120, 121, 122, 123, 131, 132, 133, 134, 135

119, 120, 121, 122

131

132, 133, 134, 135

Any TOS except 119, 120, 121, 122, 123, 131, 132, 133, 134, 135

123

Any TOS except 119, 120, 121, 122, 123, 131, 132, 133, 134, 135


    1. CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT – The appropriate values for financial transactions are shown in Table 10.


Table 10CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT values for financial transactions

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

If TYPE-OF-CLAIM = 2, then 01
If TYPE-OF-CLAIM = B then 02
If TYPE-OF-CLAIM = V then 03 or 04 as appro-priate

If TYPE-OF-CLAIM = 5, then 01
If TYPE-OF-CLAIM = E then 02
If TYPE-OF-CLAIM = Y then 03 or 04 as appro-priate

If TYPE-OF-CLAIM = 5, then 01
If TYPE-OF-CLAIM = E then 02
If TYPE-OF-CLAIM = Y then 03 or 04 as appro-priate

If TYPE-OF-CLAIM = 5, then 01
If TYPE-OF-CLAIM = E then 02
If TYPE-OF-CLAIM = Y then 03 or 04 as appropriate

If TYPE-OF-CLAIM = 2, then 01
If TYPE-OF-CLAIM = B then 02
If TYPE-OF-CLAIM = V then 03 or 04 as appro-priate

If TYPE-OF-CLAIM = 4, then 01
If TYPE-OF-CLAIM = D then 02
If TYPE-OF-CLAIM = X then 03 or 04 as appro-priate

If TYPE-OF-CLAIM = 4, then 01
If TYPE-OF-CLAIM = D then 02
If TYPE-OF-CLAIM = X then 03 or 04 as appro-priate

If TYPE-OF-CLAIM = 4, then 01
If TYPE-OF-CLAIM = D then 02
If TYPE-OF-CLAIM = X then 03 or 04 as appropriate

If TYPE-OF-CLAIM = 4, then 01
If TYPE-OF-CLAIM = D then 02
If TYPE-OF-CLAIM = X then 03 or 04 as appro-priate

If TYPE-OF-CLAIM = 4, then 01
If TYPE-OF-CLAIM = D then 02
If TYPE-OF-CLAIM = X then 03 or 04 as appropriate



o. XIX-MBESCBES-CATEGORY-OF-SERVICE – The appropriate values for financial transactions are shown in Table 11.



Table 11XIX-MBESCBES-CATEGORY-OF-SERVICE values for financial transactions

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

17A, 17B, 17C1, 18A, 18B1, 18B2, 18C, 18E, 22

7A1, 7A2, 7A3, 7A4, 7A5, 7A6

Any code

1C, 1D, 3B, 4C, 5B, 6B, 9B

17A, 17B, 17C1, 18A, 18B1, 18B2, 18C, 18E, 22

7A1, 7A2, 7A3, 7A4, 7A5, 7A6

Any code

1C, 1D, 3B, 4C, 5B, 6B, 9B

1B, 2B

Any code except 1B, 1C, 1D, 2B, 3B, 4C, 5B, 6B, 9B, 7A1, 7A2, 7A3, 7A4, 7A5, 7A6, 17A, 17B, 17C1, 18A, 18B1, 18B2 18C, 18E, 22



p. XXI-MBESCBES-CATEGORY-OF-SERVICE – The appropriate values for financial transactions are shown in Table 12.


Table 12XXI-MBESCBES-CATEGORY-OF-SERVICE values for financial transactions

At Enrollee Level

For Multiple Enrollees (i.e., a Service Tracking Claim)

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

Cap Pymt

Drug Rebate

Cost Stlmnt

Spplmntl Pymt

DSH Pymt

Other Pymt

1A, 1B, 1C, 1D, or 32B

8A

Any code

8-fill

1A, 1B, 1C, 1D, or 32B

8A

Any code

8-fill

8-fill

Any code except 1A, 1B, 1C, 1D, 32B, or 8A



Appendix P.03: Full File Replacement Submissions for Non-Claim T-MSIS File revised



Brief Issue Description

States, CMS Analysts and T-MSIS partners have provided extensive feedback regarding the complexities of submitting only changed records to T-MSIS for non-claim files (TPL, ELIGIBLE, PROVIDER and MNGDCARE). As a result, the technical requirements for submitting non-claim T-MSIS files have been modified.



CMS Guidance

CMS will now require states to submit full-file refreshes for each reporting period for the non-claims files. This supersedes the previous requirement for states to submit only those fully changed or added records that were instituted in the states’ MMIS for the reporting period (referred to as Delta records or Deltas) each month after the initial T-MSIS production submission.

CMS believes this revised approach will be less burdensome to states. If this requirement creates additional concerns for a state, please contact your CMS liaison immediately to discuss.

The following requirements and points of clarification are applicable to the submission of full-file refreshes of non-claims files:

  1. The first T-MSIS production submission for each file type provides a baseline of the State’s active Medicaid records for eligible, claims, providers, third party claims, and managed care data that were processed during the month.

  2. For each subsequent reporting period, states will submit the complete historical data content for each of the non-claims files. States will be required to submit full-file refreshes on a monthly basis, regardless of whether there are changes to submit for the reporting period.

  3. Each monthly Create submission for non-claim files will encompass a full-file refresh. Update submissions will be used to correct record errors in the Create submission that prevent them from being accepted. A Replacement submission replaces all records in the Create submission.

  4. The Replacement file will be rejected for a previous month’s submission if a Create file for the subsequent month has already been processed. An Update file will be accepted for a previous month’s submission even if a Create file for the subsequent month has already been processed.

  5. It is important to note that states are the system of record for the T-MSIS data; therefore, when states submit corrections in Update or Replacement files, the order of their submissions may overlay data that should be correctly stored in T-MSIS. When the state generates an Update file to correct rejected records, T-MSIS will process and apply those records to the data repository and that data will become the current data. It will be up to the states to ensure that Update and Replacement files are submitted in the appropriate sequence.

  6. Each time the full-file refresh is submitted for the non-claims files, T-MSIS will review the content to determine if the data already exists, identify the data that will be added or changed and the content in that full-file refresh that excludes data reported in previous months. CMS expects that, at some point in the future, the state’s MMIS will archive data from the non-claims files and will no longer report those archived records in future T-MSIS submissions.

  7. For those records that are archived in the state’s MMIS, T-MSIS will generate an informational report. T-MSIS will retain these archived records and provide the states with a report of those records after the file submissions. States will submit an Update or Replacement file when there is a need to make correction to those archived records, otherwise the records will remain in T-MSIS.

  8. All child segments must have effective time ranges that fit within the time range of their parent segments. Multiple child segments may exist for a single parent segment or multiple parent segments can exist for a single child segment; however, the time spans of multiple records for a segment should not overlap. Keep in mind that as a general rule, parent segment date spans should not have gaps.  Otherwise, the parent/child date span constraint rules will be violated. The diagram below illustrates the concept of a single child segment having multiple parent segments:

If gaps in the date span of the parent do legitimately exist, its child records should be adjusted accordingly.

  1. Parent and child records can be submitted in any order in the file. States must ensure that the parent and child segments for each record have the correct data elements identified as ‘keys’ for the segments to have the right correlation and no orphan segments exist in the file. For data elements where the state tracks the date spans, the state will submit the effective and end dates as stored in the state’s systems.

    1. Examples of segments expected to include business dates2:

      1. ELIGBILE

        1. HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

        2. HEALTH-HOME-SPA-PROVIDERS-ELG00007

        3. LOCK-IN-INFORMATION-ELG00009

        4. MFP-INFORMATION-ELG00010

        5. STATE-PLAN-OPTION-PARTICIPATION-ELG00011

        6. WAIVER-PARTICIPATION-ELG00012

        7. LTSS-PARTICIPATION-ELG00013

        8. MANAGED-CARE-PARTICIPATION-ELG00014

        9. 1115A-DEMONSTRATION-INFORMATION-ELG00018

        10. ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021

      2. PROVIDER

        1. PROV-LICENSING-INFO-PRV00004

        2. PROV-IDENTIFIERS-PRV00005

        3. PROV-TAXONOMY-CLASSIFICATION-PRV00006

        4. PROV-MEDICAID-ENROLLMENT-PRV00007

        5. PROV-AFFILIATED-GROUPS-PRV00008

        6. PROV-AFFILIATED-PROGRAMS-PRV00009

        7. PROV-BED-TYPE-INFO-PRV00010

      3. TPL

        1. TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

        2. TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

        3. TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005

      4. MNGDCARE

        1. MANAGED-CARE-MAIN-MCR00002

        2. MANAGED-CARE-SERVICE-AREA-MCR00004

        3. MANAGED-CARE-OPERATING-AUTHORITY-MCR00005

        4. MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006

        5. NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

        6. CHPID-SHPID-RELATIONSHIPS-MCR00009

  2. For data elements where the state doesn’t track the beginning and ending dates of the effective period, the state will report the value effective as of the close of the reporting period and the effective time span for these data elements will cover all time. (If the data element value changes at some point, the new value will be applicable to all time and the previous value will be considered irrelevant.)

    1. Examples of segments that are not expected to include business dates

      1. ELIGIBLE

        1. PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002

        2. VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003

        3. ELIGIBILE-CONTACT-INFORMATION-ELG00004

        4. ETHNICITY-INFORMATION-ELG00015

        5. RACE-INFORMATION-ELG00016

      2. PROVIDER

        1. PROV-ATTRIBUTES-MAIN-PRV00002

        2. PROV-LOCATION-AND-CONTACT-INFO-PRV00003

      3. TPL

        1. TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002

        2. TPL-ENTITY-CONTACT-INFORMATION-TPL00006

      4. MNGDCARE

        1. MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

The Excel workbook entitled T-MSIS Record Segment Effective Date Span Example - 2014-02-07.xlsx illustrates how CMS expects a state to populate the data elements in a record segment when some of the data elements’ values change.

  1. The monthly claims files will continue to encompass those records or transactions that occur within the start and end times of the reporting period. In other words, the full-file replacement option does not apply to claims files (CLAIMIP, CLAIMOT, CLAIMRX and CLAIMLT).



Appendix P.04: Non-Claim Full File Refreshes - Amount of History Required



How to use this guidance document

This guidance document is not intended to slow down or derail existing state development initiatives.  The intent is to provide clarification and standardization across the nation in key areas raised by state partners.   Should guidance introduce rework in ongoing development, please bring this to the attention of your TA and CMS analyst to direct you to the most appropriate path that minimizes impact to your progress.


Brief Issue Description

In its guidance on the submission of non-claim files to T-MSIS (CMS Guidance: Submission of Full-file Replacement Submissions for Non-Claims Files; released 2/18/2014 and revised 3/19/2014), CMS required states to submit the complete historical data content for each of the non-claims files in each monthly submission. Subsequent to this guidance, states have raised questions about how CMS defines the term “complete historical data content.”

This guidance document provides clarification on what CMS means by “complete historical data content.”

Background Discussion

Definitions

Non-Claim Subject Area – The general focus of the four non-claim T-MSIS files – (1) eligibility/enrollment, (2) providers, (3) managed care entities, and (4) third party liability sources.

Active – The data element values at the time the state creates the T-MSIS file which it believes to be valid and accurate for the time span bounded by the record segment’s effective and end dates.

Active” segments are not limited only to those which are effective as of the close of the reporting period. For example, an enrollee may have multiple record segments in the current tables of the state’s MMIS for time spans during which the person’s eligibility characteristics changed over time. One or all of these spans could represent “inactive eligibility” (i.e., the span’s end date is some date in the past), but these records would still need to be submitted to T-MSIS since claims with service dates falling into these time spans may exist.

Complete – All data elements on all record segments for all active records in the state’s system. Even if a data element (or even an entire record segment) is not applicable (e.g., the state does not offer a health home program), T-MSIS is still expecting an 8-filled data element, or in the case of a not-applicable record segment, a record segment with all data elements 8-filled except the two or three needed to tie the segment to its parent segment. (For example, SUBMITTING–STATE and MSIS-IDENTIFICATION-NUM is needed to tie the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 child segment to its parent (i.e., PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002))

Historical – Table 1 (T-MSIS Non-Claim, Full-File Refresh File Content Requirements by Subject Area) outlines CMS’ definition of historical data content for each of the four non-claim subject areas.

Table 1: T-MSIS Non-Claim, Full-File Refresh File Content Requirements by Subject Area

Scenario

Eligible

Provider

Managed Care

Third Party Liability

Initial T-MSIS File Submission

All active records – both those with open-ended active periods and those historical records with effective end dates going back at least to 10/1/2006 (i.e., 7 fiscal years from the 1/1/2014 T-MSIS go-live target date)3 – for all Medicaid or CHIP enrollees who:

  • Are currently enrolled;

  • Were enrolled at any time since 10/1/2006;

  • Could have claims with dates of service earlier than 10/1/2006, but which could still be adjudicated/re-adjudicated and submitted in T-MSIS claim files.

Note: MSIS eligibility data will be migrated into the T-MSIS environment. MSIS-sourced data that are overlapped by subsequent T-MSIS submissions will be end-dated so that the overlapping effective period is removed and the MSIS-sourced and T-MSIS-sourced data’s effective periods will be contiguous.

All active records – both those with open-ended active periods and those historical records with effective end dates going back at least to 10/1/2006 (i.e., 7 fiscal years from the 1/1/2014 T-MSIS go-live target date)1 – for all providers who:

  • Currently participate in Medicaid or CHIP;

  • Participated at any time since 10/1/2006, but do not currently participate;

  • Could have claims with dates of service earlier than 10/1/2006, but which could still be adjudicated/re-adjudicated and submitted in T-MSIS claim files;

  • Could have financial transactions for periods of time prior to 10/1/2006, but which could still be reported in T-MSIS claim files.

All active records – both those with open-ended active periods and those historical records with effective end dates going back at least to 10/1/2006 (i.e., 7 fiscal years from the 1/1/2014 T-MSIS go-live target date)1 – for all managed care entities that:

  • Currently contract with the state Medicaid and/or CHIP programs;

  • Contracted at any time since 10/1/2006, but do not currently do so;

  • Could have encounter records or financial transactions for periods of time prior to 10/1/2006, but which could still be reported in T-MSIS claim files.


TPL sources (health insurance and other third party sources of funds) that are actively being worked by the state at the time the initial TPL file is created.

Subsequent Months’ Submissions

Same as for the initial T-MSIS file submission, except that when the state archives records,4 these records no longer need to be included in subsequent submissions.

Same as for the initial T-MSIS file submission, except that when the state archives records,2 these records no longer need to be included in subsequent submissions.

Same as for the initial T-MSIS file submission, except that when the state archives records,2 these records no longer need to be included in subsequent submissions.

As the state resolves, closes-out, and archives cases, it can stop sending these archived records.2 New TPL sources should be added as the state becomes aware of them.



CMS Guidance

States should submit the complete, active, historical data content for the subject area in every T-MSIS non-claim, full-file refresh file as defined in Table 1, above.



Appendix P.05: Populating Qualifier Fields and Their Associated Value Fields

Brief Issue Description

The purpose of this guidance document is to when record segments need to be created for all valid values in a qualifier field’s valid value set and when it is appropriate to create a record segment for only one of the valid values.


Background Discussion


Definitions

Simple Qualifier Field – is a data element that contains a code (a.k.a. “flag”) that defines/qualifies the coding schema used when populating a set of corresponding data elements. This is necessary because there are several different schemas that a state could use and it needs to be clear which of the schemas is actually used.

Examples of “simple qualifier fields” are the DIAGNOSIS-CODE-FLAG-1 through -12 on the CLAIM-HEADER-RECORD-IP record segment (CIP00002). The valid value set for these fields is:

  1. ICD-9

  2. ICD-10

  3. Other

The state would indicate which coding schema is being used to populate the corresponding data elements DIAGNOSIS-CODE-1 through -12.


Complex Qualifier Field – is a data element that not only defines/qualifies the contents of its corresponding data elements (similar to a “simple qualifier field”), but also represents a situation where the state needs to create a record segment for each valid value that applies to the record’s subject.

An example of a “complex qualifier field is LICENSE-TYPE on the PROV-LICENSING-INFO record segment (PRV00004). The valid value set for this field is:

  1. State, county, or municipality professional or business license

  2. DEA license

  3. Professional society accreditation

  4. CLIA accreditation

  5. Other

The state would create a PROV-LICENSING-INFO record segment and populate the corresponding data elements for each LICENSE-TYPE valid value that applies to the provider.


Corresponding Data Elements – Are data elements that contain values as defined by the qualifier field.


Fully Populated Record Segment – Means that all data elements in the record segment will be populated, not just the qualifier field and its corresponding data elements. These additional data elements are necessary to enable CMS to tie the record segment to its parent segment. These data elements comprise the segment’s natural key. Generally these data elements are the ones bulleted below, but there could potentially be additional ones, depending on the record segment. See the “Record Keys & Constraints” tab in the T-MSIS Data Dictionary if there are questions concerning a record segment’s natural key.

  • RECORD-ID

  • SUBMITTING-STATE

  • RECORD-NUMBER

  • MSIS-IDENTIFICATION-NUM / STATE-PLAN-ID-NUM / SUBMITTING-STATE-PROV-ID


Record Subject – This is the individual/entity around which the record segments in a file are built. The Medicaid/CHIP enrollee is the subject of Eligible Files. In Provider Files, the subject is the provider. The managed care entity is the subject of Managed Care Files, and third party payers and their associated beneficiaries are the subjects of TPL Files.

Overview

The complex qualifier fields are included in the T-MSIS record layouts so that a given record segment layout can be used to capture a standard set of data elements (i.e., the corresponding data elements) for a category of data (i.e., the complex qualifier field’s valid values list) when more than one category may be applicable to the record subject.


The complex qualifier fields’ valid values lists are not “select one value from the valid values list and provide the corresponding data element values (which is the case for simple qualifier fields).” A separate record segment should be created and fully populated for every “complex qualifier field” valid value or unique combination of “complex qualifier field” valid value and corresponding data element value (in accordance with the Record Keys & Constraints) that applies to the record subject. Table 1 illustrates what CMS is expecting, using LICENSE-TYPE in the PROV-LICENSING-INFO record segment (PRV00004) as an example.



Example Scenario

The purpose of the PROV-LICENSING-INFO segment is to capture licensing and accreditation information relevant to a provider. The valid value list for the LICENSE-TYPE data element shows the types of information that CMS is interested in collecting in this record segment:

  1. State, county, or municipality professional or business license

  2. DEA license

  3. Professional society accreditation

  4. CLIA accreditation

  5. Other

For our example, assume three of these categories are applicable to provider # P0123: (a) a professional license issued by the state’s Board of Physicians (valid value # 1); (b.1) a board certification from the ABMS (valid value # 3); (b.2) a board certification from the AOA (also valid value # 3); and (c) a DEA number (valid value # 2). Table 1 lists the data elements in the PRV00004 record segment, and shows the contents of each data element in the four PRV00004 segments that would be required by this example.


Table 1: Examples of fully populated record segments supplying “complex qualifier field” corresponding data



Physician
License

ABMS Board
Certification

AOA Board
Certification

DEA
Number




RECORD-ID

PRV00004

PRV00004

PRV00004

PRV00004

Shape240

While these data elements aren't strictly "corresponding data elements," they are necessary to tie the segments to their parent segment.


SUBMITTING-STATE

24

24

24

24


RECORD-NUMBER

4506

4507

4508

4509


SUBMITTING-STATE-PROV-ID

P0123

P0123

P0123

P0123


PROV-LOCATION-ID

0

0

0

0

Corresponding Data Element →

PROV-LICENSE-EFF-DATE

19921119

20100101

20120701

20131001



Corresponding Data Element →

PROV-LICENSE-END-DATE

20150930

20191231

20150630

20160930




"Complex Qualifier”

Data Element →

LICENSE-TYPE

1

3

3

2



Corresponding Data Element →

LICENSE-ISSUING-ENTITY-ID

24

American Board of Medical Specialties

American Osteopathic Association

DEA



Corresponding Data Element →

LICENSE-OR-ACCREDITATION-NUMBER

D98765

IM012345

A5546

FD1234563




STATE-NOTATION








FILLER









CMS Guidance

CMS is instructing States to provide information corresponding to each of a complex qualifier field’s valid values to the extent that the valid value is applicable to the record subject. Additionally, States should fully populate the affected record segments.

In its first four columns, Table 2 displays the T-MSIS file name, record segment name, complex qualifier field name and the complex qualifier field’s list of valid values for each of the complex qualifier fields in the T-MSIS data set. The last two columns identify the corresponding data elements (along with the file segments where they reside) that need to be populated for every applicable valid value in the “complex qualifier field’s” valid value list.

Table 2: “Complex Qualifier fields” their valid values, and the corresponding data elements that need to be populated

 

File Name

"Complex Qualifier Field" Information

Corresponding Data Elements To Be Populated

Record Segment

Data Element Name

Valid Values

Record Segment

Data Element Name

1

ELIGIBLE

ELIGIBILE-CONTACT-INFORMATION (ELG00004)

ADDR-TYPE

01

Primary home address and contact information (used for the eligibility determination process)

ELIGIBILE-CONTACT-INFORMATION-ELG00004

ELIGIBLE-ADDR-LN1

 

 


 

 02

Primary work address and contact information

 

ELIGIBLE-ADDR-LN2

 

 

 

 

03

Secondary residence and contact information

 

ELIGIBLE-ADDR-LN3

 

 

 

 

04

Secondary work address and contact information

 

ELIGIBLE-CITY

 

 

 

 

05

Other category of address and contact information

 

ELIGIBLE-STATE

 

 

 

 

06

Eligible person’s official mailing address

 

ELIGIBLE-ZIP-CODE

 

 

 

 



 

ELIGIBLE-COUNTY-CODE

 

 

 

 

 

 

 

ELIGIBLE-PHONE-NUM

 

 

 

 

 

 

 

TYPE-OF-LIVING-ARRANGEMENT

ELIGIBLE-ADDR-EFF-DATE

ELIGIBLE-ADDR-END-DATE

2

MNGDCARE

MANAGED-CARE-MAIN (MCR00002)

MANAGED-CARE-SERVICE-AREA

1

Statewide – The managed care entity provides services to beneficiaries throughout the entire state.

MANAGED-CARE-SERVICE-AREA-MCR00004

MANAGED-CARE-SERVICE-AREA-NAME


 

 


 

2

County – The managed care entity provides services to beneficiaries in specified counties.


 MANAGED-CARE-SERVICE-AREA-EFF-DATE

 

 

 

 

3

City – The managed care entity provides services to beneficiaries in specified cities.

 

 MANAGED-CARE-SERVICE-AREA-END-DATE

 

 

 

 

4

Region – The managed care entity provides services to beneficiaries in specified regions, not defined by individual counties within the state (“region” is state-defined).

 

 

 

 

 

 

5

Zip Code – The managed care entity program provides services to beneficiaries in specified zip codes.

 

 

 

 

 

 

6

Other – The managed care entity provides services to beneficiaries in "other" area(s), not Statewide, County, City, or Region.

 

 

3

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO (MCR00003)

MANAGED-CARE-ADDR-TYPE

1

MCO’s corporate address and contact information

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MANAGED-CARE-LOCATION-ID

 

 


 

2

MCO’s mailing address

 

MANAGED-CARE-ADDR-LN1

 

 

 

 

3

MCO’s service location address

 

MANAGED-CARE-ADDR-LN2

 

 

 

 

4

MCO’s Billing address and contact information

 

MANAGED-CARE-ADDR-LN3

 

 

 

 

5

CEO’s address and contact information

 

MANAGED-CARE-CITY

 

 

 

 

6

CFO’s address and contact information

 

MANAGED-CARE-STATE

 

 

 

 

7

Other

 

MANAGED-CARE-ZIP-CODE

 

 

 

 

 

 

 

MANAGED-CARE-COUNTY

 

 

 

 

 

 

 

MANAGED-CARE-TELEPHONE

 

 

 

 

 

 

 

MANAGED-CARE-EMAIL

 

 

 

 

 

 

 

MANAGED-CARE-FAX-NUMBER

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE

4

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO (MCR00008)

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

1

Controlling Health Plan (CHP) ID

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

STATE-PLAN-ID-NUM

 

 


 

2

Subhealth Plan (SHP) ID

 

NATIONAL-HEALTH-CARE-ENTITY-ID

 

 

 

 

3

Other Entity Identifier (OEID)

 

NATIONAL-HEALTH-CARE-ENTITY-NAME

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE

5

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO (PRV00003)

ADDR-TYPE

1

Billing Provider

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PROV-LOCATION-ID

 

 


 

2

Provider Mailing

 

ADDR-LN1

 

 

 

 

3

Provider Practice

 

ADDR-LN2

 

 

 

 

4

Provider Service Location

 

ADDR-LN3

 

 

 

 

 

 

 

ADDR-CITY

 

 

 

 

 

 

 

ADDR-STATE

 

 

 

 

 

 

 

ADDR-ZIP-CODE

 

 

 

 

 

 

 

ADDR-TELEPHONE

 

 

 

 

 

 

 

ADDR-EMAIL

 

 

 

 

 

 

 

ADDR-FAX-NUM

 

 

 

 

 

 

 

ADDR-BORDER-STATE-IND

 

 

 

 

 

 

 

ADDR-COUNTY

PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE

PROV-LOCATION-AND-CONTACT-INFO-END-DATE

6

PROVIDER

PROV-LICENSING-INFO (PRV00004)

LICENSE-TYPE

1

State, county, or municipality professional or business license

PROV-LICENSING-INFO-PRV00004

LICENSE-OR-ACCREDITATION-NUMBER

 

 


 

2

DEA license

 

LICENSE-ISSUING-ENTITY-ID

 

 

 

 

3

Professional society accreditation

 

PROV-LICENSE-EFF-DATE

 

 

 

 

4

CLIA accreditation

 

 PROV-LICENSE-END-DATE

 

 

 

 

5

Other

 

 

7

PROVIDER

PROV-IDENTIFIERS (PRV00005)

PROV-IDENTIFIER-TYPE

1

State-specific Medicaid Provider ID

PROV-IDENTIFIERS-PRV00005

PROV-IDENTIFIER

 

 


 

2

NPI

 

PROV-IDENTIFIER-ISSUING-ENTITY-ID

 

 

 

 

3

Medicare ID

 

PROV-IDENTIFIER-EFF-DATE


 

 

 

 

4

NCPDP ID

 

PROV-IDENTIFIER-END-DATE 

 

 

 

 

5

Federal Tax ID

 

 

 

 

 

 

6

State Tax ID

 

 

 

 

 

 

7

SSN

 

 

 

 

 

 

8

Other

 

 

8

PROVIDER

PROV-TAXONOMY-CLASSIFICATION (PRV00006)

PROV-CLASSIFICATION-TYPE

1

Taxonomy code

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PROV-CLASSIFICATION-CODE

 

 


 

2

Provider specialty code

 

PROV-TAXONOMY-CLASSIFICATION-EFF-DATE

 

 

 

 

 

3

Provider type code

 

PROV-TAXONOMY-CLASSIFICATION-END-DATE 

 

 

 

 

4

Authorized category of service code

 

 

9

PROVIDER

PROV-AFFILIATED-PROGRAMS

AFFILIATED-PROGRAM-TYPE

1

Health Plan (NHP-ID)

PROV-AFFILIATED-PROGRAMS-PRV00009

AFFILIATED-PROGRAM-ID

 

 

PRV00009

 

2

Health Plan (state-assigned health plan ID)

 

 PROV-AFFILIATED-PROGRAM-EFF-DATE

 

 

 

 

3

Waiver

 

PROV-AFFILIATED-PROGRAM-END-DATE 

 

 

 

 

4

Health Home Entity

 

 

 

 

 

 

5

Other

 

 

10

TPL

TPL-ENTITY-CONTACT-INFORMATION

TPL-ENTITY-ADDR-TYPE

06

TPL-Entity Corporate Location

TPL-ENTITY-CONTACT-INFORMATION-TPL00006

INSURANCE-CARRIER-ADDR-LN1

 

 

(TPL00006)

 

07

TPL-Entity Mailing

 

INSURANCE-CARRIER-ADDR-LN2

 

 

 

 

08

TPL-Entity Satellite Location

 

INSURANCE-CARRIER-ADDR-LN3

 

 

 

 

09

TPL-Entity Billing

 

INSURANCE-CARRIER-CITY

 

 

 

 

10

TPL-Entity Correspondence

 

INSURANCE-CARRIER-STATE

 

 

 

 

11

TPL-Other

 

INSURANCE-CARRIER-ZIP-CODE

 

 

 

 

 

 

 

INSURANCE-CARRIER-PHONE-NUM

INSURANCE-CARRIER-NAIC-CODE

INSURANCE-CARRIER-NAME

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

NATIONAL-HEALTH-CARE-ENTITY-ID

NATIONAL-HEALTH-CARE-ENTITY-NAME

TPL-ENTITY-CONTACT-INFO-EFF-DATE

TPL-ENTITY-CONTACT-INFO-END-DATE





Appendix P.06: IIFI (Inter/Intra-File Indices)



How to use this guidance document

This guidance document is intended to provide clarification on previous guidance or clarification to requirement areas that states need to assist in the development and implementation of T-MSIS file submissions.


Brief Issue Description

This document provides information about T-MSIS Inter/Intra-File Indices (IIFI) data elements and an additional set of important data elements; both comprise a subset of the overall T-MSIS

data elements.


Background Discussion

The IIFI data elements are made up of three groups.

  1. Ten Logical Record Keys and eleven File Header Keys. Logical Keys are keys that are used in parent child relationship queries and in the creation of the logical records in the Federal T-MSIS data model. File Header Keys are keys that are required on the T-MSIS File header segments.

Source-to-target matrices submitted by states ideally should report each of these corresponding twenty-one data elements with a Data Source Availability of "Always". We expect that 100 percent of the twenty-one group one IIFI data elements are to be reported as “Always” when CMS compares the files submitted to the State’s Source-to-Target Mapping document. CMS envisions that no problem will exist in compliance to the reporting of group one elements.

  1. Twenty Program Specific Segment keys. Program Specific Segment keys comprise of data elements that are keys used in identifying records uniquely in a Program Specific segment in the T-MSIS files. These are also keys are used for updating the records in the data warehouse for those Program specific segments. Program Specific data refer to whether states are participating in any of five Medicaid/CHIP program areas (1115A waiver, Money-Follows-the-Person (MFP), Lock-In-Providers, Health Home SPAs, and Managed Care participation). There are twenty Program Specific segment keys – applicable to specific programs.

Regarding this second group of Program Specific data elements, the presence or absence of these data elements in the State’s T-MSIS submission, of course, depends on whether the State is participating in one or more of the five Medicaid/CHIP program areas (1115A waiver, Money-Follows-the-Person (MFP), Lock-In-Providers, Health Home SPAs, and Managed Care participation). When States participate in one or more of the ‘Medicaid/CHIP Program areas’, the source-to-target matrices ideally should report each of the corresponding Program Specific data elements with a Data Source Availability of "Always" or “Sometimes”.

When States do not participate in a ‘program area’, their source-to-target matrices ideally should report each of the corresponding Program Specific data elements with a Data Source Availability of "Never".

  1. 211 Segment keys. These segment keys only differ from the second group in that they are non-program specific, and are relevant to all states, regardless if they are included in the second group. Segment keys comprise of data elements that are keys used in identifying records uniquely in a segment in the T-MSIS files. These are also keys are used for updating the records in the data warehouse for those segments.

States should follow these guidelines when building records.

  • States must provide primary keys (as listed below) in all segments irrespective of segment being applicable to the state.

  • Coding segments which are ‘not applicable’ for all records;



Example – if the State does not operate a HEALTH-HOME, the State must populate one record in the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment with key values for SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM and ‘8-fill’ all other elements in the segment. This should be completed for every enrollee in the file.

RECORD-ID

1

SUBMITTING-STATE

11

RECORD-NUMBER

1

MSIS-IDENTIFICATION-NUM

456698821

HEALTH-HOME-SPA-NAME

8-fill

HEALTH-HOME-ENTITY-NAME

8-fill

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

8-fill

HEALTH-HOME-SPA-PARTICIPATION-END-DATE

8-fill

HEALTH-HOME-ENTITY-EFF-DATE

8-fill

STATE-NOTATION

8-fill

FILLER




  • Coding segments which are ‘not applicable’ for some records and ‘applicable’ for other records;



Example - when a state operates a HEALTH-HOME for enrollees who are not enrolled in a HEALTH-HOME - code segments which are ‘not applicable’;



If the State has an approved HEALTH-HOME SPA, the State must populate one record in the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment with key values for SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM and ‘8-fill’ all other elements in the segment. This should be completed for every enrollee in the file that is not enrolled in a HEALTH HOME.

RECORD-ID

1

SUBMITTING-STATE

11

RECORD-NUMBER

1

MSIS-IDENTIFICATION-NUM

789550702245

HEALTH-HOME-SPA-NAME

8-fill

HEALTH-HOME-ENTITY-NAME

8-fill

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

8-fill

HEALTH-HOME-SPA-PARTICIPATION-END-DATE

8-fill

HEALTH-HOME-ENTITY-EFF-DATE

8-fill

STATE-NOTATION

8-fill

FILLER




Example - when a state operates a HEALTH-HOME for enrollees who are enrolled in a HEALTH-HOME - coding segments which are ‘applicable’;

If the State has an approved HEALTH-HOME SPA, the State must populate one record in the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment with key values for SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, and code all other fields appropriately with data that are applicable for the situation. This should be completed for every enrollee in the file that is enrolled in a HEALTH HOME

RECORD-ID

1

SUBMITTING-STATE

11

RECORD-NUMBER

1

MSIS-IDENTIFICATION-NUM

2335-445-07

HEALTH-HOME-SPA-NAME

Happy-Go-Lucky Inc.

HEALTH-HOME-ENTITY-NAME

Health Homes of DC.

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

20140101

HEALTH-HOME-SPA-PARTICIPATION-END-DATE

20140131

HEALTH-HOME-ENTITY-EFF-DATE

20130701

STATE-NOTATION


FILLER




  • Coding segments when segments are ‘applicable’ but data values are ‘unknown’ at certain points in time.



If the State has an approved HEALTH-HOME SPA, the State must populate one record in the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 segment with key values for SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM and ‘9-fill’ the elements in the segment . This should be completed for every enroll in the file that is enrolled in a HEALTH HOME



RECORD-ID

1

SUBMITTING-STATE

11

RECORD-NUMBER

1

MSIS-IDENTIFICATION-NUM

789550702245

HEALTH-HOME-SPA-NAME

Golden Years HH

HEALTH-HOME-ENTITY-NAME

9-fill

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

9-fill

HEALTH-HOME-SPA-PARTICIPATION-END-DATE

9-fill

HEALTH-HOME-ENTITY-EFF-DATE

9-fill

STATE-NOTATION

9-fill

FILLER





Data Elements by File Name

Tables 1-8 below contain 448 IIFI data elements with their data element number. These tables represent a duplicated list of the IIFI data element subset found in groups 1-3. Table 9 is the unduplicated listing of 21 IIFI data elements.



Tables 10 –15 contain data elements with their data element number. This represents the 20 Program Specific data elements found in the 2nd group (Program Specific segment keys subset). Table 16 is the unduplicated list of 20 Program Specific data elements.

The unique data element number (DE No), data element name, file name, and file segment are listed in each chart.

Note that data element names in these tables are duplicated on multiple file segments and multiple files.

Table

File Name

1

Eligible

2

TPL

3

Managed Care

4

Provider

5

Claim OT

6

Claim RX

7

Claim LT

8

Claim IP



Table 1: Eligible IIFI Data Elements (132 IIFIs)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

ELG001

RECORD-ID

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG002

DATA-DICTIONARY-VERSION

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG003

SUBMISSION-TRANSACTION-TYPE

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG004

FILE-ENCODING-SPECIFICATION

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG005

DATA-MAPPING-DOCUMENT-VERSION

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG006

FILE-NAME

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG007

SUBMITTING-STATE

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG009

START-OF-TIME-PERIOD

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG010

END-OF-TIME-PERIOD

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG011

FILE-STATUS-INDICATOR

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG012

SSN-INDICATOR

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG013

TOT-REC-CNT

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG247

SEQUENCE-NUMBER

ELIGIBLE

FILE-HEADER-RECORD-ELIGIBILITY-ELG00001

ELG016

RECORD-ID

ELIGIBLE

PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002

ELG017

SUBMITTING-STATE

ELIGIBLE

PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002

ELG018

RECORD-NUMBER

ELIGIBLE

PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002

ELG019

MSIS-IDENTIFICATION-NUM

ELIGIBLE

PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002

ELG026

PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE

ELIGIBLE

PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002

ELG030

RECORD-ID

ELIGIBLE

VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003

ELG031

SUBMITTING-STATE

ELIGIBLE

VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003

ELG032

RECORD-NUMBER

ELIGIBLE

VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003

ELG033

MSIS-IDENTIFICATION-NUM

ELIGIBLE

VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003

ELG057

VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE

ELIGIBLE

VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003

ELG061

RECORD-ID

ELIGIBLE

ELIGIBILE-CONTACT-INFORMATION-ELG00004

ELG062

SUBMITTING-STATE

ELIGIBLE

ELIGIBILE-CONTACT-INFORMATION-ELG00004

ELG063

RECORD-NUMBER

ELIGIBLE

ELIGIBILE-CONTACT-INFORMATION-ELG00004

ELG064

MSIS-IDENTIFICATION-NUM

ELIGIBLE

ELIGIBILE-CONTACT-INFORMATION-ELG00004

ELG065

ADDR-TYPE

ELIGIBLE

ELIGIBILE-CONTACT-INFORMATION-ELG00004

ELG075

ELIGIBLE-ADDR-EFF-DATE

ELIGIBLE

ELIGIBILE-CONTACT-INFORMATION-ELG00004

ELG079

RECORD-ID

ELIGIBLE

ELIGIBILITY-DETERMINANTS-ELG00005

ELG080

SUBMITTING-STATE

ELIGIBLE

ELIGIBILITY-DETERMINANTS-ELG00005

ELG081

RECORD-NUMBER

ELIGIBLE

ELIGIBILITY-DETERMINANTS-ELG00005

ELG082

MSIS-IDENTIFICATION-NUM

ELIGIBLE

ELIGIBILITY-DETERMINANTS-ELG00005

ELG083

MSIS-CASE-NUM

ELIGIBLE

ELIGIBILITY-DETERMINANTS-ELG00005

ELG099

ELIGIBILITY-DETERMINANT-EFF-DATE

ELIGIBLE

ELIGIBILITY-DETERMINANTS-ELG00005

ELG103

RECORD-ID

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG104

SUBMITTING-STATE

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG105

RECORD-NUMBER

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG106

MSIS-IDENTIFICATION-NUM

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG233

1115A-DEMONSTRATION-IND

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG234

1115A-EFF-DATE

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG132

HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG114

RECORD-ID

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG115

SUBMITTING-STATE

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG116

RECORD-NUMBER

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG117

MSIS-IDENTIFICATION-NUM

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG131

HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG108

HEALTH-HOME-ENTITY-NAME

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG119

HEALTH-HOME-ENTITY-NAME

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG126

RECORD-ID

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG127

SUBMITTING-STATE

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG128

RECORD-NUMBER

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG129

MSIS-IDENTIFICATION-NUM

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG120

HEALTH-HOME-PROV-NUM

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG107

HEALTH-HOME-SPA-NAME

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG118

HEALTH-HOME-SPA-NAME

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG130

HEALTH-HOME-CHRONIC-CONDITION

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG136

RECORD-ID

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG137

SUBMITTING-STATE

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG138

RECORD-NUMBER

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG139

MSIS-IDENTIFICATION-NUM

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG109

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG121

HEALTH-HOME-SPA-PROVIDER-EFF-DATE

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG142

LOCKIN-EFF-DATE

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG146

RECORD-ID

ELIGIBLE

MFP-INFORMATION-ELG00010

ELG147

SUBMITTING-STATE

ELIGIBLE

MFP-INFORMATION-ELG00010

ELG148

RECORD-NUMBER

ELIGIBLE

MFP-INFORMATION-ELG00010

ELG149

MSIS-IDENTIFICATION-NUM

ELIGIBLE

MFP-INFORMATION-ELG00010

ELG140

LOCKIN-PROV-NUM

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG159

RECORD-ID

ELIGIBLE

STATE-PLAN-OPTION-PARTICIPATION-ELG00011

ELG160

SUBMITTING-STATE

ELIGIBLE

STATE-PLAN-OPTION-PARTICIPATION-ELG00011

ELG161

RECORD-NUMBER

ELIGIBLE

STATE-PLAN-OPTION-PARTICIPATION-ELG00011

ELG162

MSIS-IDENTIFICATION-NUM

ELIGIBLE

STATE-PLAN-OPTION-PARTICIPATION-ELG00011

ELG163

STATE-PLAN-OPTION-TYPE

ELIGIBLE

STATE-PLAN-OPTION-PARTICIPATION-ELG00011

ELG164

STATE-PLAN-OPTION-EFF-DATE

ELIGIBLE

STATE-PLAN-OPTION-PARTICIPATION-ELG00011

ELG168

RECORD-ID

ELIGIBLE

WAIVER-PARTICIPATION-ELG00012

ELG169

SUBMITTING-STATE

ELIGIBLE

WAIVER-PARTICIPATION-ELG00012

ELG170

RECORD-NUMBER

ELIGIBLE

WAIVER-PARTICIPATION-ELG00012

ELG171

MSIS-IDENTIFICATION-NUM

ELIGIBLE

WAIVER-PARTICIPATION-ELG00012

ELG172

WAIVER-ID

ELIGIBLE

WAIVER-PARTICIPATION-ELG00012

ELG174

WAIVER-ENROLLMENT-EFF-DATE

ELIGIBLE

WAIVER-PARTICIPATION-ELG00012

ELG178

RECORD-ID

ELIGIBLE

LTSS-PARTICIPATION-ELG00013

ELG179

SUBMITTING-STATE

ELIGIBLE

LTSS-PARTICIPATION-ELG00013

ELG180

RECORD-NUMBER

ELIGIBLE

LTSS-PARTICIPATION-ELG00013

ELG181

MSIS-IDENTIFICATION-NUM

ELIGIBLE

LTSS-PARTICIPATION-ELG00013

ELG182

LTSS-LEVEL-CARE

ELIGIBLE

LTSS-PARTICIPATION-ELG00013

ELG183

LTSS-PROV-NUM

ELIGIBLE

LTSS-PARTICIPATION-ELG00013

ELG184

LTSS-ELIGIBILITY-EFF-DATE

ELIGIBLE

LTSS-PARTICIPATION-ELG00013

ELG188

RECORD-ID

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014

ELG189

SUBMITTING-STATE

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014

ELG190

RECORD-NUMBER

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014

ELG191

MSIS-IDENTIFICATION-NUM

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014

ELG141

LOCKIN-PROV-TYPE

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG196

MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014

ELG192

MANAGED-CARE-PLAN-ID

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014

ELG155

MFP-ENROLLMENT-EFF-DATE

ELIGIBLE

MFP-INFORMATION-ELG00010

ELG200

RECORD-ID

ELIGIBLE

ETHNICITY-INFORMATION-ELG00015

ELG201

SUBMITTING-STATE

ELIGIBLE

ETHNICITY-INFORMATION-ELG00015

ELG202

RECORD-NUMBER

ELIGIBLE

ETHNICITY-INFORMATION-ELG00015

ELG203

MSIS-IDENTIFICATION-NUM

ELIGIBLE

ETHNICITY-INFORMATION-ELG00015

ELG204

ETHNICITY-CODE

ELIGIBLE

ETHNICITY-INFORMATION-ELG00015

ELG205

ETHNICITY-DECLARATION-EFF-DATE

ELIGIBLE

ETHNICITY-INFORMATION-ELG00015

ELG209

RECORD-ID

ELIGIBLE

RACE-INFORMATION-ELG00016

ELG210

SUBMITTING-STATE

ELIGIBLE

RACE-INFORMATION-ELG00016

ELG211

RECORD-NUMBER

ELIGIBLE

RACE-INFORMATION-ELG00016

ELG212

MSIS-IDENTIFICATION-NUM

ELIGIBLE

RACE-INFORMATION-ELG00016

ELG213

RACE

ELIGIBLE

RACE-INFORMATION-ELG00016

ELG214

RACE-OTHER

ELIGIBLE

RACE-INFORMATION-ELG00016

ELG216

RACE-DECLARATION-EFF-DATE

ELIGIBLE

RACE-INFORMATION-ELG00016

ELG220

RECORD-ID

ELIGIBLE

DISABILITY-INFORMATION-ELG00017

ELG221

SUBMITTING-STATE

ELIGIBLE

DISABILITY-INFORMATION-ELG00017

ELG222

RECORD-NUMBER

ELIGIBLE

DISABILITY-INFORMATION-ELG00017

ELG223

MSIS-IDENTIFICATION-NUM

ELIGIBLE

DISABILITY-INFORMATION-ELG00017

ELG224

DISABILITY-TYPE-CODE

ELIGIBLE

DISABILITY-INFORMATION-ELG00017

ELG225

DISABILITY-TYPE-EFF-DATE

ELIGIBLE

DISABILITY-INFORMATION-ELG00017

ELG229

RECORD-ID

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG230

SUBMITTING-STATE

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG231

RECORD-NUMBER

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG232

MSIS-IDENTIFICATION-NUM

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG235

1115A-END-DATE

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG238

RECORD-ID

ELIGIBLE

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020

ELG239

SUBMITTING-STATE

ELIGIBLE

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020

ELG240

RECORD-NUMBER

ELIGIBLE

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020

ELG241

MSIS-IDENTIFICATION-NUM

ELIGIBLE

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020

ELG242

HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE

ELIGIBLE

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020

ELG243

HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE

ELIGIBLE

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020

ELG248

RECORD-ID

ELIGIBLE

ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021

ELG249

SUBMITTING-STATE

ELIGIBLE

ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021

ELG250

RECORD-NUMBER

ELIGIBLE

ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021

ELG251

MSIS-IDENTIFICATION-NUM

ELIGIBLE

ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021

ELG252

ENROLLMENT-TYPE

ELIGIBLE

ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021

ELG253

ENROLLMENT-EFF-DATE

ELIGIBLE

ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021

Table 2: TPL IIFI Data Elements (47 IIFIs)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

TPL001

RECORD-ID

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL002

DATA-DICTIONARY-VERSION

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL003

SUBMISSION-TRANSACTION-TYPE

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL004

FILE-ENCODING-SPECIFICATION

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL005

DATA-MAPPING-DOCUMENT-VERSION

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL006

FILE-NAME

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL007

SUBMITTING-STATE

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL009

START-OF-TIME-PERIOD

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL010

END-OF-TIME-PERIOD

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL011

FILE-STATUS-INDICATOR

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL012

SSN-INDICATOR

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL013

TOT-REC-CNT

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL088

SEQUENCE-NUMBER

TPL

FILE-HEADER-RECORD-TPL-TPL00001

TPL016

RECORD-ID

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002

TPL017

SUBMITTING-STATE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002

TPL018

RECORD-NUMBER

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002

TPL019

MSIS-IDENTIFICATION-NUM

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002

TPL025

ELIG-PRSN-MAIN-EFF-DATE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002

TPL029

RECORD-ID

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL030

SUBMITTING-STATE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL031

RECORD-NUMBER

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL032

MSIS-IDENTIFICATION-NUM

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL033

INSURANCE-CARRIER-ID-NUM

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL034

INSURANCE-PLAN-ID

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL035

GROUP-NUM

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL036

MEMBER-ID

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL089

COVERAGE-TYPE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL048

INSURANCE-COVERAGE-EFF-DATE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003

TPL052

RECORD-ID

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

TPL053

SUBMITTING-STATE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

TPL054

RECORD-NUMBER

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

TPL055

INSURANCE-CARRIER-ID-NUM

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

TPL056

INSURANCE-PLAN-ID

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

TPL058

COVERAGE-TYPE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

TPL059

INSURANCE-CATEGORIES-EFF-DATE

TPL

TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004

TPL063

RECORD-ID

TPL

TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005

TPL064

SUBMITTING-STATE

TPL

TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005

TPL065

RECORD-NUMBER

TPL

TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005

TPL066

MSIS-IDENTIFICATION-NUM

TPL

TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005

TPL067

TYPE-OF-OTHER-THIRD-PARTY-LIABILITY

TPL

TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005

TPL068

OTHER-TPL-EFF-DATE

TPL

TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005

TPL072

RECORD-ID

TPL

TPL-ENTITY-CONTACT-INFORMATION-TPL00006

TPL073

SUBMITTING-STATE

TPL

TPL-ENTITY-CONTACT-INFORMATION-TPL00006

TPL074

RECORD-NUMBER

TPL

TPL-ENTITY-CONTACT-INFORMATION-TPL00006

TPL075

INSURANCE-CARRIER-ID-NUM

TPL

TPL-ENTITY-CONTACT-INFORMATION-TPL00006

TPL076

TPL-ENTITY-ADDR-TYPE

TPL

TPL-ENTITY-CONTACT-INFORMATION-TPL00006

TPL084

TPL-ENTITY-CONTACT-INFO-EFF-DATE

TPL

TPL-ENTITY-CONTACT-INFORMATION-TPL00006



Table 3: Managed Care IIFI Data Elements (62 IIFI)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

MCR001

RECORD-ID

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR002

DATA-DICTIONARY-VERSION

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR003

SUBMISSION-TRANSACTION-TYPE

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR004

FILE-ENCODING-SPECIFICATION

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR005

DATA-MAPPING-DOCUMENT-VERSION

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR006

FILE-NAME

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR007

SUBMITTING-STATE

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR009

START-OF-TIME-PERIOD

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR010

END-OF-TIME-PERIOD

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR011

FILE-STATUS-INDICATOR

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR013

TOT-REC-CNT

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR112

SEQUENCE-NUMBER

MNGDCARE

FILE-HEADER-RECORD-MANAGED-CARE-MCR00001

MCR016

RECORD-ID

MNGDCARE

MANAGED-CARE-MAIN-MCR00002

MCR017

SUBMITTING-STATE

MNGDCARE

MANAGED-CARE-MAIN-MCR00002

MCR018

RECORD-NUMBER

MNGDCARE

MANAGED-CARE-MAIN-MCR00002

MCR019

STATE-PLAN-ID-NUM

MNGDCARE

MANAGED-CARE-MAIN-MCR00002

MCR030

MANAGED-CARE-MAIN-REC-EFF-DATE

MNGDCARE

MANAGED-CARE-MAIN-MCR00002

MCR034

RECORD-ID

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MCR035

SUBMITTING-STATE

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MCR036

RECORD-NUMBER

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MCR037

STATE-PLAN-ID-NUM

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MCR038

MANAGED-CARE-LOCATION-ID

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MCR039

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MCR041

MANAGED-CARE-ADDR-TYPE

MNGDCARE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003

MCR054

RECORD-ID

MNGDCARE

MANAGED-CARE-SERVICE-AREA-MCR00004

MCR055

SUBMITTING-STATE

MNGDCARE

MANAGED-CARE-SERVICE-AREA-MCR00004

MCR056

RECORD-NUMBER

MNGDCARE

MANAGED-CARE-SERVICE-AREA-MCR00004

MCR057

STATE-PLAN-ID-NUM

MNGDCARE

MANAGED-CARE-SERVICE-AREA-MCR00004

MCR058

MANAGED-CARE-SERVICE-AREA-NAME

MNGDCARE

MANAGED-CARE-SERVICE-AREA-MCR00004

MCR059

MANAGED-CARE-SERVICE-AREA-EFF-DATE

MNGDCARE

MANAGED-CARE-SERVICE-AREA-MCR00004

MCR063

RECORD-ID

MNGDCARE

MANAGED-CARE-OPERATING-AUTHORITY-MCR00005

MCR064

SUBMITTING-STATE

MNGDCARE

MANAGED-CARE-OPERATING-AUTHORITY-MCR00005

MCR065

RECORD-NUMBER

MNGDCARE

MANAGED-CARE-OPERATING-AUTHORITY-MCR00005

MCR066

STATE-PLAN-ID-NUM

MNGDCARE

MANAGED-CARE-OPERATING-AUTHORITY-MCR00005

MCR067

OPERATING-AUTHORITY

MNGDCARE

MANAGED-CARE-OPERATING-AUTHORITY-MCR00005

MCR069

MANAGED-CARE-OP-AUTHORITY-EFF-DATE

MNGDCARE

MANAGED-CARE-OPERATING-AUTHORITY-MCR00005

MCR073

RECORD-ID

MNGDCARE

MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006

MCR074

SUBMITTING-STATE

MNGDCARE

MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006

MCR075

RECORD-NUMBER

MNGDCARE

MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006

MCR076

STATE-PLAN-ID-NUM

MNGDCARE

MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006

MCR077

MANAGED-CARE-PLAN-POP

MNGDCARE

MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006

MCR078

MANAGED-CARE-PLAN-POP-EFF-DATE

MNGDCARE

MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006

MCR082

RECORD-ID

MNGDCARE

MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007

MCR083

SUBMITTING-STATE

MNGDCARE

MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007

MCR084

RECORD-NUMBER

MNGDCARE

MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007

MCR085

STATE-PLAN-ID-NUM

MNGDCARE

MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007

MCR086

ACCREDITATION-ORGANIZATION

MNGDCARE

MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007

MCR087

DATE-ACCREDITATION-ACHIEVED

MNGDCARE

MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007

MCR091

RECORD-ID

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR092

SUBMITTING-STATE

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR093

RECORD-NUMBER

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR094

STATE-PLAN-ID-NUM

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR095

NATIONAL-HEALTH-CARE-ENTITY-ID

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR096

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR098

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR102

RECORD-ID

MNGDCARE

CHPID-SHPID-RELATIONSHIPS-MCR00009

MCR103

SUBMITTING-STATE

MNGDCARE

CHPID-SHPID-RELATIONSHIPS-MCR00009

MCR104

RECORD-NUMBER

MNGDCARE

CHPID-SHPID-RELATIONSHIPS-MCR00009

MCR105

STATE-PLAN-ID-NUM

MNGDCARE

CHPID-SHPID-RELATIONSHIPS-MCR00009

MCR106

CHPID

MNGDCARE

CHPID-SHPID-RELATIONSHIPS-MCR00009

MCR107

SHPID

MNGDCARE

CHPID-SHPID-RELATIONSHIPS-MCR00009

MCR108

CHPID-SHPID-RELATIONSHIP-EFF-DATE

MNGDCARE

CHPID-SHPID-RELATIONSHIPS-MCR00009


Table 4: Provider IIFI Data Elements (74 IIFIs)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

PRV001

RECORD-ID

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV002

DATA-DICTIONARY-VERSION

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV003

SUBMISSION-TRANSACTION-TYPE

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV004

FILE-ENCODING-SPECIFICATION

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV005

DATA-MAPPING-DOCUMENT-VERSION

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV006

FILE-NAME

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV007

SUBMITTING-STATE

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV009

START-OF-TIME-PERIOD

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV010

END-OF-TIME-PERIOD

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV011

FILE-STATUS-INDICATOR

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV013

TOT-REC-CNT

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV138

SEQUENCE-NUMBER

PROVIDER

FILE-HEADER-RECORD-PROVIDER-PRV00001

PRV016

RECORD-ID

PROVIDER

PROV-ATTRIBUTES-MAIN-PRV00002

PRV017

SUBMITTING-STATE

PROVIDER

PROV-ATTRIBUTES-MAIN-PRV00002

PRV018

RECORD-NUMBER

PROVIDER

PROV-ATTRIBUTES-MAIN-PRV00002

PRV019

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-ATTRIBUTES-MAIN-PRV00002

PRV020

PROV-ATTRIBUTES-EFF-DATE

PROVIDER

PROV-ATTRIBUTES-MAIN-PRV00002

PRV039

RECORD-ID

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PRV040

SUBMITTING-STATE

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PRV041

RECORD-NUMBER

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PRV042

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PRV043

PROV-LOCATION-ID

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PRV044

PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PRV046

ADDR-TYPE

PROVIDER

PROV-LOCATION-AND-CONTACT-INFO-PRV00003

PRV060

RECORD-ID

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV061

SUBMITTING-STATE

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV062

RECORD-NUMBER

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV063

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV064

PROV-LOCATION-ID

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV065

PROV-LICENSE-EFF-DATE

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV067

LICENSE-TYPE

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV068

LICENSE-ISSUING-ENTITY-ID

PROVIDER

PROV-LICENSING-INFO-PRV00004

PRV072

RECORD-ID

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV073

SUBMITTING-STATE

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV074

RECORD-NUMBER

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV075

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV076

PROV-LOCATION-ID

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV077

PROV-IDENTIFIER-TYPE

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV078

PROV-IDENTIFIER-ISSUING-ENTITY-ID

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV079

PROV-IDENTIFIER-EFF-DATE

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV081

PROV-IDENTIFIER

PROVIDER

PROV-IDENTIFIERS-PRV00005

PRV084

RECORD-ID

PROVIDER

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PRV085

SUBMITTING-STATE

PROVIDER

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PRV086

RECORD-NUMBER

PROVIDER

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PRV087

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PRV088

PROV-CLASSIFICATION-TYPE

PROVIDER

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PRV089

PROV-CLASSIFICATION-CODE

PROVIDER

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PRV090

PROV-TAXONOMY-CLASSIFICATION-EFF-DATE

PROVIDER

PROV-TAXONOMY-CLASSIFICATION-PRV00006

PRV094

RECORD-ID

PROVIDER

PROV-MEDICAID-ENROLLMENT-PRV00007

PRV095

SUBMITTING-STATE

PROVIDER

PROV-MEDICAID-ENROLLMENT-PRV00007

PRV096

RECORD-NUMBER

PROVIDER

PROV-MEDICAID-ENROLLMENT-PRV00007

PRV097

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-MEDICAID-ENROLLMENT-PRV00007

PRV098

PROV-MEDICAID-EFF-DATE

PROVIDER

PROV-MEDICAID-ENROLLMENT-PRV00007

PRV100

PROV-MEDICAID-ENROLLMENT-STATUS-CODE

PROVIDER

PROV-MEDICAID-ENROLLMENT-PRV00007

PRV106

RECORD-ID

PROVIDER

PROV-AFFILIATED-GROUPS-PRV00008

PRV107

SUBMITTING-STATE

PROVIDER

PROV-AFFILIATED-GROUPS-PRV00008

PRV108

RECORD-NUMBER

PROVIDER

PROV-AFFILIATED-GROUPS-PRV00008

PRV109

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-AFFILIATED-GROUPS-PRV00008

PRV110

SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY

PROVIDER

PROV-AFFILIATED-GROUPS-PRV00008

PRV111

PROV-AFFILIATED-GROUP-EFF-DATE

PROVIDER

PROV-AFFILIATED-GROUPS-PRV00008

PRV115

RECORD-ID

PROVIDER

PROV-AFFILIATED-PROGRAMS-PRV00009

PRV116

SUBMITTING-STATE

PROVIDER

PROV-AFFILIATED-PROGRAMS-PRV00009

PRV117

RECORD-NUMBER

PROVIDER

PROV-AFFILIATED-PROGRAMS-PRV00009

PRV118

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-AFFILIATED-PROGRAMS-PRV00009

PRV119

AFFILIATED-PROGRAM-TYPE

PROVIDER

PROV-AFFILIATED-PROGRAMS-PRV00009

PRV120

AFFILIATED-PROGRAM-ID

PROVIDER

PROV-AFFILIATED-PROGRAMS-PRV00009

PRV121

PROV-AFFILIATED-PROGRAM-EFF-DATE

PROVIDER

PROV-AFFILIATED-PROGRAMS-PRV00009

PRV125

RECORD-ID

PROVIDER

PROV-BED-TYPE-INFO-PRV00010

PRV126

SUBMITTING-STATE

PROVIDER

PROV-BED-TYPE-INFO-PRV00010

PRV127

RECORD-NUMBER

PROVIDER

PROV-BED-TYPE-INFO-PRV00010

PRV128

SUBMITTING-STATE-PROV-ID

PROVIDER

PROV-BED-TYPE-INFO-PRV00010

PRV129

PROV-LOCATION-ID

PROVIDER

PROV-BED-TYPE-INFO-PRV00010

PRV130

BED-TYPE-EFF-DATE

PROVIDER

PROV-BED-TYPE-INFO-PRV00010

PRV134

BED-TYPE-CODE

PROVIDER

PROV-BED-TYPE-INFO-PRV00010


Table 5: Claim OT IIFI Data Elements (34 IIFIs)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

COT001

RECORD-ID

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT002

DATA-DICTIONARY-VERSION

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT003

SUBMISSION-TRANSACTION-TYPE

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT004

FILE-ENCODING-SPECIFICATION

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT005

DATA-MAPPING-DOCUMENT-VERSION

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT006

FILE-NAME

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT007

SUBMITTING-STATE

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT009

START-OF-TIME-PERIOD

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT010

END-OF-TIME-PERIOD

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT011

FILE-STATUS-INDICATOR

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT012

SSN-INDICATOR

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT013

TOT-REC-CNT

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT216

SEQUENCE-NUMBER

CLAIMOT

FILE-HEADER-RECORD-OT-COT00001

COT016

RECORD-ID

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT017

SUBMITTING-STATE

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT018

RECORD-NUMBER

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT019

ICN-ORIG

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT020

ICN-ADJ

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT025

ADJUSTMENT-IND

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT033

BEGINNING-DATE-OF-SERVICE

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT035

ADJUDICATION-DATE

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT040

CLAIM-STATUS-CATEGORY

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT112

BILLING-PROV-NUM

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT117

REFERRING-PROV-NUM

CLAIMOT

CLAIM-HEADER-RECORD-OT-COT00002

COT154

RECORD-ID

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT155

SUBMITTING-STATE

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT156

RECORD-NUMBER

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT158

ICN-ORIG

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT159

ICN-ADJ

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT160

LINE-NUM-ORIG

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT161

LINE-NUM-ADJ

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT166

BEGINNING-DATE-OF-SERVICE

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT189

SERVICING-PROV-NUM

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

COT221

ADJUDICATION-DATE

CLAIMOT

CLAIM-LINE-RECORD-OT-COT00003

Table 6: Claim RX IIFI Data Elements (32 IIFIs)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

CRX001

RECORD-ID

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX002

DATA-DICTIONARY-VERSION

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX003

SUBMISSION-TRANSACTION-TYPE

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX004

FILE-ENCODING-SPECIFICATION

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX005

DATA-MAPPING-DOCUMENT-VERSION

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX006

FILE-NAME

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX007

SUBMITTING-STATE

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX009

START-OF-TIME-PERIOD

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX010

END-OF-TIME-PERIOD

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX011

FILE-STATUS-INDICATOR

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX012

SSN-INDICATOR

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX013

TOT-REC-CNT

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX155

SEQUENCE-NUMBER

CLAIMRX

FILE-HEADER-RECORD-RX-CRX00001

CRX016

RECORD-ID

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX017

SUBMITTING-STATE

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX018

RECORD-NUMBER

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX019

ICN-ORIG

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX020

ICN-ADJ

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX025

ADJUSTMENT-IND

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX027

ADJUDICATION-DATE

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX031

CLAIM-STATUS-CATEGORY

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX070

BILLING-PROV-NUM

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX074

PRESCRIBING-PROV-NUM

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX156

DISPENSING-PRESCRIPTION-DRUG-PROV-NUM

CLAIMRX

CLAIM-HEADER-RECORD-RX-CRX00002

CRX108

RECORD-ID

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003

CRX109

SUBMITTING-STATE

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003

CRX110

RECORD-NUMBER

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003

CRX112

ICN-ORIG

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003

CRX113

ICN-ADJ

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003

CRX114

LINE-NUM-ORIG

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003

CRX115

LINE-NUM-ADJ

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003

CRX157

ADJUDICATION-DATE

CLAIMRX

CLAIM-LINE-RECORD-RX-CRX00003



Table 7: Claim LT IIFI Data Elements (34 IIFIs)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

CLT001

RECORD-ID

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT002

DATA-DICTIONARY-VERSION

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT003

SUBMISSION-TRANSACTION-TYPE

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT004

FILE-ENCODING-SPECIFICATION

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT005

DATA-MAPPING-DOCUMENT-VERSION

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT006

FILE-NAME

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT007

SUBMITTING-STATE

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT009

START-OF-TIME-PERIOD

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT010

END-OF-TIME-PERIOD

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT011

FILE-STATUS-INDICATOR

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT012

SSN-INDICATOR

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT013

TOT-REC-CNT

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT227

SEQUENCE-NUMBER

CLAIMLT

FILE-HEADER-RECORD-LT-CLT00001

CLT016

RECORD-ID

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT017

SUBMITTING-STATE

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT018

RECORD-NUMBER

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT019

ICN-ORIG

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT020

ICN-ADJ

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT025

ADJUSTMENT-IND

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT048

BEGINNING-DATE-OF-SERVICE

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT050

ADJUDICATION-DATE

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT055

CLAIM-STATUS-CATEGORY

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT130

BILLING-PROV-NUM

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT135

REFERRING-PROV-NUM

CLAIMLT

CLAIM-HEADER-RECORD-LT-CLT00002

CLT184

RECORD-ID

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT185

SUBMITTING-STATE

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT186

RECORD-NUMBER

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT188

ICN-ORIG

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT189

ICN-ADJ

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT190

LINE-NUM-ORIG

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT191

LINE-NUM-ADJ

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT196

BEGINNING-DATE-OF-SERVICE

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT212

SERVICING-PROV-NUM

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

CLT233

ADJUDICATION-DATE

CLAIMLT

CLAIM-LINE-RECORD-LT-CLT00003

Table 8: Claim IP IIFI Data Elements (33 IIFIs)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

CIP001

RECORD-ID

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP002

DATA-DICTIONARY-VERSION

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP003

SUBMISSION-TRANSACTION-TYPE

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP004

FILE-ENCODING-SPECIFICATION

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP005

DATA-MAPPING-DOCUMENT-VERSION

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP006

FILE-NAME

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP007

SUBMITTING-STATE

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP009

START-OF-TIME-PERIOD

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP010

END-OF-TIME-PERIOD

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP011

FILE-STATUS-INDICATOR

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP012

SSN-INDICATOR

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP013

TOT-REC-CNT

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP275

SEQUENCE-NUMBER

CLAIMIP

FILE-HEADER-RECORD-IP-CIP00001

CIP016

RECORD-ID

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP017

SUBMITTING-STATE

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP018

RECORD-NUMBER

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP019

ICN-ORIG

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP020

ICN-ADJ

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP026

ADJUSTMENT-IND

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP098

ADJUDICATION-DATE

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP103

CLAIM-STATUS-CATEGORY

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP179

BILLING-PROV-NUM

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP189

REFERRING-PROV-NUM

CLAIMIP

CLAIM-HEADER-RECORD-IP-CIP00002

CIP231

RECORD-ID

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP232

SUBMITTING-STATE

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP233

RECORD-NUMBER

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP235

ICN-ORIG

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP236

ICN-ADJ

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP237

LINE-NUM-ORIG

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP238

LINE-NUM-ADJ

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP243

BEGINNING-DATE-OF-SERVICE

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP260

SERVICING-PROV-NUM

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003

CIP286

ADJUDICATION-DATE

CLAIMIP

CLAIM-LINE-RECORD-IP-CIP00003


IIFI Data Element Names

Table 9 contains a listing of unique data element names that represent the IIFI subset. While 448 total IIFI data elements exist, only 122 unique data element names exist. This data element name duplication is due to data element names that are required in each file segment, such as 'Submitting-State' and 'Record-Number'.

Table 9: Unique IIFI Data Elements (122)

Data Element Name

1115A-DEMONSTRATION-IND

1115A-EFF-DATE

ACCREDITATION-ORGANIZATION

ADDR-TYPE

ADJUDICATION-DATE

ADJUSTMENT-IND

AFFILIATED-PROGRAM-ID

AFFILIATED-PROGRAM-TYPE

BED-TYPE-CODE

BED-TYPE-EFF-DATE

BEGINNING-DATE-OF-SERVICE

BILLING-PROV-NUM

CHPID

CHPID-SHPID-RELATIONSHIP-EFF-DATE

CLAIM-STATUS-CATEGORY

COVERAGE-TYPE

DATA-DICTIONARY-VERSION

DATA-MAPPING-DOCUMENT-VERSION

DATE-ACCREDITATION-ACHIEVED

DISABILITY-TYPE-CODE

DISABILITY-TYPE-EFF-DATE

DISPENSING-PRESCRIPTION-DRUG-PROV-NUM

ELIGIBILITY-DETERMINANT-EFF-DATE

ELIGIBLE-ADDR-EFF-DATE

ELIG-PRSN-MAIN-EFF-DATE

END-OF-TIME-PERIOD

ENROLLMENT-EFF-DATE

ENROLLMENT-TYPE

ETHNICITY-CODE

ETHNICITY-DECLARATION-EFF-DATE

FILE-ENCODING-SPECIFICATION

FILE-NAME

FILE-STATUS-INDICATOR

GROUP-NUM

HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE

HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE

HEALTH-HOME-CHRONIC-CONDITION

HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE

HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION

HEALTH-HOME-ENTITY-NAME

HEALTH-HOME-PROV-NUM

HEALTH-HOME-SPA-NAME

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

HEALTH-HOME-SPA-PROVIDER-EFF-DATE

ICN-ADJ

ICN-ORIG

INSURANCE-CARRIER-ID-NUM

INSURANCE-CATEGORIES-EFF-DATE

INSURANCE-COVERAGE-EFF-DATE

INSURANCE-PLAN-ID

LICENSE-ISSUING-ENTITY-ID

LICENSE-TYPE

LINE-NUM-ADJ

LINE-NUM-ORIG

LOCKIN-EFF-DATE

LOCKIN-PROV-NUM

LOCKIN-PROV-TYPE

LTSS-ELIGIBILITY-EFF-DATE

LTSS-LEVEL-CARE

LTSS-PROV-NUM

MANAGED-CARE-ADDR-TYPE

MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE

MANAGED-CARE-LOCATION-ID

MANAGED-CARE-MAIN-REC-EFF-DATE

MANAGED-CARE-OP-AUTHORITY-EFF-DATE

MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE

MANAGED-CARE-PLAN-ID

MANAGED-CARE-PLAN-POP

MANAGED-CARE-PLAN-POP-EFF-DATE

MANAGED-CARE-SERVICE-AREA-EFF-DATE

MANAGED-CARE-SERVICE-AREA-NAME

MEMBER-ID

MFP-ENROLLMENT-EFF-DATE

MSIS-CASE-NUM

MSIS-IDENTIFICATION-NUM

NATIONAL-HEALTH-CARE-ENTITY-ID

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

OPERATING-AUTHORITY

OTHER-TPL-EFF-DATE

PRESCRIBING-PROV-NUM

PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE

PROV-AFFILIATED-GROUP-EFF-DATE

PROV-AFFILIATED-PROGRAM-EFF-DATE

PROV-ATTRIBUTES-EFF-DATE

PROV-CLASSIFICATION-CODE

PROV-CLASSIFICATION-TYPE

PROV-IDENTIFIER

PROV-IDENTIFIER-EFF-DATE

PROV-IDENTIFIER-ISSUING-ENTITY-ID

PROV-IDENTIFIER-TYPE

PROV-LICENSE-EFF-DATE

PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE

PROV-LOCATION-ID

PROV-MEDICAID-EFF-DATE

PROV-MEDICAID-ENROLLMENT-STATUS-CODE

PROV-TAXONOMY-CLASSIFICATION-EFF-DATE

RACE

RACE-DECLARATION-EFF-DATE

RACE-OTHER

RECORD-ID

RECORD-NUMBER

REFERRING-PROV-NUM

SEQUENCE-NUMBER

SERVICING-PROV-NUM

SHPID

SSN-INDICATOR

START-OF-TIME-PERIOD

STATE-PLAN-ID-NUM

STATE-PLAN-OPTION-EFF-DATE

STATE-PLAN-OPTION-TYPE

SUBMISSION-TRANSACTION-TYPE

SUBMITTING-STATE

SUBMITTING-STATE-PROV-ID

SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY

TOT-REC-CNT

TPL-ENTITY-ADDR-TYPE

TPL-ENTITY-CONTACT-INFO-EFF-DATE

TYPE-OF-OTHER-THIRD-PARTY-LIABILITY

VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE

WAIVER-ENROLLMENT-EFF-DATE

WAIVER-ID


Program Specific Data Elements

Table 10: Eligible – 1115 Demonstration – (2 Program Specific Data Elements)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

ELG233

1115A-DEMONSTRATION-IND

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018

ELG234

1115A-EFF-DATE

ELIGIBLE

1115A-DEMONSTRATION-INFORMATION-ELG00018



Table 11: Eligible – Health Home – (9 Program Specific Data Elements)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

ELG132

HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG131

HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION

ELIGIBLE

HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008

ELG108

HEALTH-HOME-ENTITY-NAME

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG107

HEALTH-HOME-SPA-NAME

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG109

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

ELIGIBLE

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006

ELG119

HEALTH-HOME-ENTITY-NAME

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG120

HEALTH-HOME-PROV-NUM

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG118

HEALTH-HOME-SPA-NAME

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007

ELG121

HEALTH-HOME-SPA-PROVIDER-EFF-DATE

ELIGIBLE

HEALTH-HOME-SPA-PROVIDERS-ELG00007



Table 12: Eligible – Lock-In Provider – (3 Program Specific Data Elements)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

ELG142

LOCKIN-EFF-DATE

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG140

LOCKIN-PROV-NUM

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009

ELG141

LOCKIN-PROV-TYPE

ELIGIBLE

LOCK-IN-INFORMATION-ELG00009



Table 13: Eligible – Managed-Care-Participation – (2 Program Specific Data Elements)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

ELG196

MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014

ELG192

MANAGED-CARE-PLAN-ID

ELIGIBLE

MANAGED-CARE-PARTICIPATION-ELG00014



Table 14: Eligible – Money Follows the Person – (1 Program Specific Data Element)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

ELG155

MFP-ENROLLMENT-EFF-DATE

ELIGIBLE

MFP-INFORMATION-ELG00010



Table 15: Managed Care – (3 Program Specific Data Elements)

DE No

Data Element Name

FILE NAME

File Segment (with Record-ID)

MCR095

NATIONAL-HEALTH-CARE-ENTITY-ID

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR096

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

MCR098

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE

MNGDCARE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008

Program Specific Data Element Names

The following table contains a listing of 20 unique data element names that represent the Program Specific data element subset.

Table 16: Unique Program Specific Data Elements (20)

Data Element Name

1115A-DEMONSTRATION-IND

1115A-EFF-DATE

HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE

HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION

HEALTH-HOME-ENTITY-NAME

HEALTH-HOME-ENTITY-NAME

HEALTH-HOME-PROV-NUM

HEALTH-HOME-SPA-NAME

HEALTH-HOME-SPA-NAME

HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE

HEALTH-HOME-SPA-PROVIDER-EFF-DATE

LOCKIN-EFF-DATE

LOCKIN-PROV-NUM

LOCKIN-PROV-TYPE

MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE

MANAGED-CARE-PLAN-ID

MFP-ENROLLMENT-EFF-DATE

NATIONAL-HEALTH-CARE-ENTITY-ID

NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE



CMS Guidance

Since the IIFI and Program Specific data elements are of such fundamental importance to file integrity and data analysis, the state will be asked to review how IIFI and Program Specific data elements marked with “never” or “sometimes” availability can be upgraded to “always”(when applicable). Therefore, states should review each IIFI and Program Specific (when applicable) data element and reevaluate its ability to provide these data elements in its final consolidated 8 file submission.



Appendix P.07: Finding Provider Roles on STD Transactions


How to use this guidance document

This guidance document is not intended to slow down or derail existing state development initiatives.  The intent is to provide clarification and standardization across the nation in key areas raised by state partners.   Should guidance introduce rework in ongoing development, please bring this to the attention of your TA and CMS analyst to direct you to the most appropriate path that minimizes impact to your progress.

Brief Issue Description

Some States have requested assistance with identifying where to find in the X-12 claim transaction sets the NPIs and taxonomy codes of providers who performed various roles associated with the claim/encounter.


Background Discussion

Definitions

Provider role – The function that a specific provider performed for a particular patient on specified dates of service, and which are contained on fee-for-service claims or reported on encounter records. The particular roles that CMS would like to track on T-MSIS claims are:

  • Admitting (attending) provider

  • Billing provider

  • Dispensing provider

  • Operating provider

  • Prescribing provider

  • Referring provider

  • Servicing (rendering) provider

  • Under supervision of provider

Provider role information needed for the T-MSIS claim files can be extracted from the standard X-12 transactions. The five tables in the “CMS Guidance” section of this document provide T-MSIS-toX-12 crosswalks for each provider role. The five tables are:

Table A: Provider roles on T-MSIS CLAIMIP files and their corresponding locations on the X-12 transactions

Table B: Provider roles on T-MSIS CLAIMLT files and their corresponding locations on the X-12 transactions

Table C: Provider roles on T-MSIS CLAIMOT (facility claims) files and their corresponding locations on the X-12 transactions

Table D: Provider roles on T-MSIS CLAIMOT (professional claims) files and their corresponding locations on the X-12 transactions

Table E: Provider roles on T-MSIS CLAIMOT (dental claims) files and their corresponding locations on the X-12 transactions

Table F: Provider roles on T-MSIS CLAIMRX files and their corresponding locations on the X-12 transactions

In each table, the first column identifies the provider role. The second and third columns identify the specific T-MSIS record segments and data elements used to capture the NPI and taxonomy of the provider performing the specified role. The fourth, fifth, sixth, and seventh columns in tables “A” through “E” provide the X-12 transaction name, data element identifier, data element description and loop id that map to the T-MSIS data element. The fourth, fifth, sixth, and seventh columns in table “F” provide the segment name, field identifier, field name and definition of the applicable NCPDP D.0 data set fields.

CMS Guidance

Use tables “A” through “F” to map the provider roles that are contained in the T-MSIS claim record layouts to their corresponding X-12 standard transaction data elements.

If the T-MSIS data element does not exist in the X-12 transaction set (shown as “N/A” in the tables below), 8-fill the T-MSIS data element when building T-MSIS claim files.





Table A: Provider roles on T-MSIS CLAIMIP files and their corresponding locations on the X-12 transactions

Provider Role

IP –

T-MSIS Data element & Record Segment

X-12

Transaction Information

Data Element

Record Segment

Transaction

Element Identifier

Description

Loop

Conditional Rules

Admitting (Attending)

 

ADMITTING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-IP-CIP00002

5010 A2 837-I Institutional Claim

NM109

Attending Provider Identifier

2310A


ADMITTING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-IP-CIP00002

 5010 A2 837-I Institutional Claim

PRV03

Provider Taxonomy Code

2310A


Billing

 

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-IP-CIP00002

5010 A2 837-I Institutional Claim

NM109

Billing Provider Identifier

2010AA


BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-IP-CIP00002

 5010 A2 837-I Institutional Claim

PRV03

Provider Taxonomy Code

2000A


Operating

 

OPERATING-PROV-NPI-NUM

CLAIM-LINE-RECORD-IP-CIP00003

5010 A2 837-I Institutional Claim

NM109

Operating Physician Identifier

2310B or 2420A

The identifier in the 837i loop 2310B could be applied to each line in T-MSIS except for lines where there is a different identifier in loop 2420A at the line level of the 837i. If there is a different identifier in 837i loop 2420A then the identifier from loop 2420A should be reported as the operating provider identifier.

OPERATING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-IP-CIP00002

N/A

N/A

N/A

N/A


Referring

 

REFERRING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-IP-CIP00002

5010 A2 837-I Institutional Claim

NM109

Referring Provider Identifier

2310F or 2420D

The identifier in the 837i loop 2310F could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420D at the line level of the 837i. If there is a different identifier in 837i loop 2420D then the identifier from 2420D should be reported as the referring provider identifier.

REFERRING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-IP-CIP00002

N/A

N/A

N/A

N/A


Servicing (Rendering)

 

SERVICING-PROV-NPI-NUM

CLAIM-LINE-RECORD-IP-CIP00003

5010 A2 837-I Institutional Claim

NM109

Rendering Provider Identifier

2310D or 2420C

The identifier in the 837i loop 2310D could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420C at the line level of the 837i. If there is a different identifier in 837i loop 2420C then the identifier from loop 2420C should be reported as the servicing/rendering provider identifier.

SERVICING-PROV-TAXONOMY

CLAIM-LINE-RECORD-IP-CIP00003

N/A

N/A

N/A

N/A


Under-Direction-of

 

UNDER-DIRECTION-OF-PROV-NPI

CLAIM-HEADER-RECORD-IP-CIP00002

N/A

N/A

N/A

N/A


UNDER-DIRECTION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-IP-CIP00002

N/A

N/A

N/A

N/A


Under-Supervision-of

 

UNDER-SUPERVISION-OF-PROV-NPI

CLAIM-HEADER-RECORD-IP-CIP00002

N/A

N/A

N/A

N/A


UNDER-SUPERVISION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-IP-CIP00002

N/A

N/A

N/A

N/A




Table B: Provider roles on T-MSIS CLAIMLT files and their corresponding locations on the X-12 transactions

Provider Role

LT –

T-MSIS Data element & Record Segment

X-12

Transaction Information

Data Element

Record Segment

Transaction

Element Identifier

Description

Loop

Conditional Rules

Admitting (Attending)

ADMITTING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-LT-CLT00002

5010 A2 837-I Institutional Claim

NM109

Attending Provider Identifier

2310A



ADMITTING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-LT-CLT00002


PRV03

Provider Taxonomy Code

2310A


Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-LT-CLT00002

5010 A2 837-I Institutional Claim

NM109

Billing Provider Identifier

2010AA



BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-LT-CLT00002


PRV03

Provider Taxonomy Code

2000A


Referring

REFERRING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-LT-CLT00002

5010 A2 837-I Institutional Claim

NM109

Referring Provider Identifier

2310F or 2420D

The identifier in the 837i loop 2310F could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420D at the line level of the 837i. If there is a different identifier in 837i loop 2420D then the identifier from 2420D should be reported as the referring provider identifier.


REFERRING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-LT-CLT00002

N/A

N/A

N/A

N/A


Servicing (Rendering)

SERVICING-PROV-NPI-NUM

CLAIM-LINE-RECORD-LT-CLT00003

5010 A2 837-I Institutional Claim

NM109

Rendering Provider Identifier

2310D or 2420C

The identifier in the 837i loop 2310D could be applied to each line in T-MSIS except for lines where there is a different identifier in loop 2420C at the line level of the 837i. If there is a different identifier in 837i loop 2420C then the identifier from loop 2420C should be reported as the servicing/rendering provider identifier.


SERVICING-PROV-TAXONOMY

CLAIM-LINE-RECORD-LT-CLT00003

N/A

N/A

N/A

N/A


Under-Direction-of

UNDER-DIRECTION-OF-PROV-NPI

CLAIM-HEADER-RECORD-LT-CLT00002

N/A

N/A

N/A

N/A



UNDER-DIRECTION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-LT-CLT00002

N/A

N/A

N/A

N/A


Under-Supervision-of

UNDER-SUPERVISION-OF-PROV-NPI

CLAIM-HEADER-RECORD-LT-CLT00002

N/A

N/A

N/A

N/A


 

UNDER-SUPERVISION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-LT-CLT00002

N/A

N/A

N/A

N/A




Table C: Provider roles on T-MSIS CLAIMOT (facility claims) files and their corresponding locations on the X-12 transactions

Provider Role

OT (facility) –

T-MSIS Data element & Record Segment

X-12

Transaction Information

Data Element

Record Segment

Transaction

Element Identifier

Description

Loop

Conditional Rules

Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-OT-COT00002

5010 A2 837-I Institutional Claim

NM109

Billing Provider Identifier

2010AA



BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

5010 A2 837-I Institutional Claim

PRV03

Provider Taxonomy Code

2000A


Referring

REFERRING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-OT-COT00002

5010 A2 837-I Institutional Claim

NM109

Referring Provider Identifier

2310F or 2420D

The identifier in the 837i loop 2310F could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420D at the line level of the 837i. If there is a different identifier in 837i loop 2420D then the identifier from 2420D should be reported as the referring provider identifier.


REFERRING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A


Servicing (Rendering)

SERVICING-PROV-NPI-NUM

CLAIM-LINE-RECORD-OT-COT00003

5010 A2 837-I Institutional Claim

NM109

Rendering Provider Identifier

2310D or 2420C

The identifier in the 837i loop 2310D could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420C at the line level of the 837i. If there is a different identifier in 837i loop 2420C then the identifier from loop 2420C should be reported as the servicing/rendering provider identifier.


SERVICING-PROV-TAXONOMY

CLAIM-LINE-RECORD-OT-COT00003

N/A

N/A

N/A

N/A


Under-Direction-of

UNDER-DIRECTION-OF-PROV-NPI

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A



UNDER-DIRECTION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A


Under-Supervision-of

UNDER-SUPERVISION-OF-PROV-NPI

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A


 

UNDER-SUPERVISION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A




Table D: Provider roles on T-MSIS CLAIMOT (professional claims) files and their corresponding locations on the X-12 transactions

Provider Role

OT (professional) –

T-MSIS Data element & Record Segment

X-12

Transaction Information

Data Element

Record Segment

Transaction

Element Identifier

Description

Loop

Conditional Rules

Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-P Professional Claim


NM109

Billing Provider Identifier

2010AA



BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-P Professional Claim


PRV03

Provider Taxonomy Code

2000A


Referring

REFERRING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-P Professional Claim


NM109

Referring Provider Identifier

2310A or 2420F

The identifier in the 837p loop 2310A could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420F at the line level of the 837p. If there is a different identifier in 837p loop 2420F then the identifier from 2420F should be reported as the referring provider identifier.


REFERRING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A


Servicing (Rendering)

SERVICING-PROV-NPI-NUM

CLAIM-LINE-RECORD-OT-COT00003

5010 A1 837-P Professional Claim


NM109

Rendering Provider Identifier

2310B or 2420A

The identifier in the 837p loop 2310B could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420A at the line level of the 837p. If there is a different identifier in 837p loop 2420A then the identifier from 2420A should be reported as the servicing/rendering provider identifier.


SERVICING-PROV-TAXONOMY

CLAIM-LINE-RECORD-OT-COT00003

5010 A1 837-P Professional Claim


PRV03

Provider Taxonomy Code

2310B or 2420A

The taxonomy in the 837p loop 2310B could be applied to each line in T-MSIS except for lines where there is a different taxonomy in 2420A at the line level of the 837p. If there is a different taxonomy in 837p loop 2420A then the taxonomy from 2420A should be reported as the servicing/rendering provider taxonomy.

Under-Direction-of

UNDER-DIRECTION-OF-PROV-NPI

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A



UNDER-DIRECTION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A


Under-Supervision-of

UNDER-SUPERVISION-OF-PROV-NPI

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-P Professional Claim

NM109

Supervising Provider Identifier

2310D or 2420D

The identifier in the 837p loop 2310D could be applied to each line in T-MSIS except for lines where there is a different identifier in loop 2420D at the line level of the 837p. If there is a different identifier in loop 2420D then the identifier from loop 2420D should be reported as the under-supervision-of provider identifier.


UNDER-SUPERVISION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A




Table E: Provider roles on T-MSIS CLAIMOT (dental claims) files and their corresponding locations on the X-12 transactions

Provider Role

OT (dental) –

T-MSIS Data element & Record Segment

X-12

Transaction Information

Data Element

Record Segment

Transaction

Element Identifier

Description

Loop

Conditional Rules

Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-D Dental Claim

NM109

Billing Provider Identifier

2010AA



BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-D Dental Claim

PRV03

Provider Taxonomy Code

2000A


Referring

REFERRING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-D Dental Claim

NM109

Referring Provider Identifier

2310A



REFERRING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A


Servicing (Rendering)

SERVICING-PROV-NPI-NUM

CLAIM-LINE-RECORD-OT-COT00003

5010 A1 837-D Dental Claim

NM109

Rendering Provider Identifier

2310B or 2420A

The identifier in 837d loop 2310B could be applied to each line in T-MSIS except for lines where there is a different identifier in 2420A at the line level of the 837d. If there is a different identifier in 837d) loop 2420A then the identifier from 2420A should be reported as the servicing/rendering provider identifier.


SERVICING-PROV-TAXONOMY

CLAIM-LINE-RECORD-OT-COT00003

5010 A1 837-D Dental Claim

PRV03

Provider Taxonomy Code

2310B or 2420A

The taxonomy in the 837d loop 2310B could be applied to each line in T-MSIS except for lines where there is a different taxonomy in 2420A at the line level of the 837p. If there is a different taxonomy in 837p loop 2420A then the taxonomy from 2420A should be reported as the servicing/rendering provider taxonomy.

Under-Direction-of

UNDER-DIRECTION-OF-PROV-NPI

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A



UNDER-DIRECTION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A


Under-Supervision-of

UNDER-SUPERVISION-OF-PROV-NPI

CLAIM-HEADER-RECORD-OT-COT00002

5010 A1 837-D Dental Claim

NM109

Supervising Provider Identifier

2310E or 2420C

The identifier in the 837d loop 2310E could be applied to each line in T-MSIS except for lines where there is a different identifier in loop 2420C at the line level of the 837d. If there is a different identifier in loop 2420C then the identifier from loop 2420C should be reported as the under-supervision-of provider identifier.


UNDER-SUPERVISION-OF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OT-COT00002

N/A

N/A

N/A

N/A




Table F: Provider roles on T-MSIS CLAIMRX (prescription drug) files and their corresponding locations on the X-12 transactions

Provider Role

Rx –

T-MSIS Data element & Record Segment

X-12

Transaction Information

Data Element

Record Segment

Segment

Field

Field Name

Definition

Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-RX-CRX00002

NCPDP D.0 - Transaction Header Segment

201-B1

Service Provider ID

ID assigned to a pharmacy or provider

 

BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-RX-CRX00002

N/A

N/A

N/A

N/A

Dispensing

DISPENSING-PRESCRIPTION-DRUG-PROV-NPI

CLAIM-HEADER-RECORD-RX-CRX00002

NCPDP D.0 - Pharmacy Provider Segment

444-E9

Provider ID

ID assigned to a pharmacy or provider individual responsible for dispensing the prescription

 

DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY

CLAIM-HEADER-RECORD-RX-CRX00002

N/A

N/A

N/A

N/A

Prescribing

PRESCRIBING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-RX-CRX00002

NCPDP D.0 - Prescriber Segment

411-DB

Prescriber ID

ID assigned to the prescriber

 

PRESCRIBING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-RX-CRX00002

N/A

N/A

N/A

N/A




Appendix Q: Terms and Abbreviations

Acronym/Abbreviation Description

AAAHC Accreditation Association for Ambulatory Health Care, Inc.

ABD Aged, Blind and Disabled

ACA Affordable Care Act

ADA American Dental Association

ADDR Address

AFDC Aid to Families with Dependent Children

AIDS Acquired Immunodeficiency Syndrome

AMT Amount

ANSI American National Standards Institute

APC Ambulatory payment classifications

APPL Application

ARNP Advanced Registered Nurse Practitioner

ASC Ambulatory Surgical Center

ASCII American Standard Code for Information Interchange

ATP Ability-To-Pay

BIP Balancing Incentive Program

BMI Body Mass Index

BOE Basis of Eligibility

CBSA Core Based Statistical Area

CD Code

CDIB Certificate of Degree of Indian or Alaska Native Blood

CEO Chief Executive Officer

CFO Chief Financial Officer

CFR Code of Federal Regulations

CHIP Children’s Health Insurance Program

CHIPRA Children’s Health Insurance Program Reauthorization Act

CHPID Controlling Health Plan Identifiers

CLIA Clinical Laboratory Improvement Amendment

CMCS Center for Medicaid, CHIP and Surveys and Certifications

CMHC Community Mental Health Center

CMMI Center for Medicare and Medicaid Innovation

CMS Centers for Medicare & Medicaid Services

COBOL Common Business Oriented Language

COBRA Consolidated Omnibus Budget Reconciliation Act of 1986

COLA Cost-of-Living Adjustment

CORF Comprehensive Outpatient Rehabilitation Facility

COV Covered

CPE Certified Public Expenditures

CPT Current Procedural Terminology

CRNA Certified Registered Nurse Anesthetists

CRVS California Relative Value Study

CWF Common Working File

DBA Doing Business As

DEA Drug Enforcement Agency

DED Deductible

DME Durable Medical Equipment

DO Doctor of osteopathy

DRG Diagnosis Related Group

DSH Disproportionate Share Hospital

DSN Data Set Name

DTL Detail

DUR Drug Utilization Review

EBCDIC Extended Binary-Coded-Decimal Interchange Code

EDI Electronic Data Interchange

EFF Effective

EFT Electronic Funds Transfer; or Electronic File Transfer

EPSDT Early and Periodic Screening, Diagnosis, and Treatment

ESI Employer Sponsored Insurance

ESRD End Stage Renal Disease

FFP Federal Financial Participation

FFS Fee-for-Service

FFY Federal Fiscal Year

FFYQ Federal Fiscal Year Quarter

FI Fiscal Intermediary

FL Form Locator

FLF Fixed Length Format

FPL Federal Poverty Level

FQHC Federally Qualified Health Center

GME Graduate Medical Education

HCBS Home and Community-Based Services

HCC RA Hierarchical Condition Category Risk Assessment

HCFA Health Care Financing Administration

HCPCS Health Care Procedural Coding System

HETS HIPAA Eligibility Transaction System

HHA Home Health Agency

HHPPS Home Health Prospective Payment System

Hib Haemophilus influenza type b

HIC Health Insurance Claim

HICN Health Insurance Claim Number

HIFA Health Insurance and Flexibility and Accountability

HIO Health Insurance Organization

HIPAA Health Insurance Portability and Accountably Act of 1996

HIV Human immunodeficiency virus

HMO Health Maintenance Organization

HPV Human Papillomavirus

IBM International Business Machines, Inc.

ICD International Classification of Diseases

ICD-10-CM The 10th revision of the ICD

ICD-9-CM The 9th revision of the ICD

ICF Intermediate Care Facility

ICF-IID Intermediate Care Facility for Individuals with Intellectual Disabilities

ICN Item Control Number

IGT Intergovernmental Transfers

IHS Indian Health Service

IHS-BCC IHS-B

IHS-BIP IHS-B

IMD Institution for Mental Disease

INA Immigration and Nationality Act

IND Indicator

IP Inpatient

IPFPPS Inpatient Psychiatric Facility Prospective Payment System

IPPS Acute Inpatient Prospective Payment System

IRFPPS Inpatient Rehabilitation Facility Prospective Payment System

LN Line

LPN Licensed Practical Nurse

LPR Lawful permanent residents

LT Long Term

LTC Long Term Care

LTCHPPS Long Term Care Hospital Prospective Payment System

LTCLA Long Term Care Living Arrangement

LTSS Long Term Services and Support

MACPro Medicaid and CHIP Program Data System

MAGI Modified Adjusted Gross Income

MAS Maintenance Assistance Status

MBI Medicare Beneficiary Identifier

M-CHIP Medicaid Expansion CHIP

MCO Managed Care Organization

MCR Managed Care Record

MD Medical Doctor

MFP Money Follows the Person

MH Mental Health

MMA Medicare Modernization Act

MMIS Medicaid Management Information System

MOD Modifiers

MRI Magnetic resonance imaging

MS-DRG Medicare Severity – Diagnosis Related Group

MSIS Medicaid Statistical Information System

MSP Medicare Secondary Payer

NAIC National Association of Insurance Commissioners

NCPDP National Council for Prescription Drug Programs

NDC National Drug Code

NF Nursing Facility

NHP-ID National Health Plan Identifier

NPI National Provider ID

OASDI Old-Age, Survivors, and Disability Insurance

OEID Other Entity Identifier

OIG Office of Inspector General

OIS Office of Information Services

OMB Office of Management and Budget

OPPS Outpatient Prospective Payment System

ORF Other Rehabilitation Facility

OS Operating System

OT Other Type [of claim]

OTC Over the counter

PACE Program for All-Inclusive Care for the Elderly

PAHP Prepaid Ambulatory Health Plan

PBM Pharmacy Benefits Manager

PCCM Primary Care Case Management

PERS Personal Emergency Response System

PHP Prepaid Health Plan

PHS Public Health Service Act

PIHP Prepaid Inpatient Health Plan

PL Public Law

POA Present on Admission

POP Population

PPS Prospective Payment System

PROV Provider

PRTF Psychiatric Residential Treatment Facilities Demonstration Grant Program

PRWORA Personal Responsibility and Work Opportunity Reconciliation Act of 1996

PT/OT/ST Physical Therapy/Occupational Therapy/Speech Therapy

QDWI Qualified Disabled Working Individuals

QI Qualified Individual

QIO Quality Improvement Organization

QMB Qualified Medicare Beneficiaries

RA Remittance Advice

RBRVS Resource-based relative value scale

REC Record

RHC Rural health clinic

RN Registered Nurse

RRB Railroad Retirement Board

RX Prescription

SCHIP State Children’s Health Insurance Program

SHPID Sub-Health Plan Identifiers

SLMB Specified Low-Income Medicare Beneficiaries

SNF Skilled Nursing Facility

SNFPPS Skilled Nursing Facility Prospective Payment System

SPA State Plan Amendment

SSA Social Security Administration

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

SSP State Supplemental Program

SSN Social Security Number

SUD Substance Use Disorders

T-18 SNF Title 18 Skilled Nursing Facility

TANF Temporary Assistance for Needy Families

TB Tuberculosis

TEFRA Tax Equity and Fiscal Responsibility Act of 1982

TIN Tax Identifier Number

T-MSIS Transformed Medicaid Statistical Information System

TOT Total

TPL Third Party Liability

TWWIIA Ticket to Work and Work Incentives Improvement Act

UB Uniform Billing

URAC Utilization Review Accreditation Commission

USC United States Code

VA Veterans Administration











[1][1] CMS will provide direction at a later date concerning resubmission of records that states are unable to correct.

[1][1] CMS will provide direction at a later date concerning resubmission of records that states are unable to correct.

[1][1] CMS will provide direction at a later date concerning resubmission of records that states are unable to correct.

[1][1] CMS will provide direction at a later date concerning resubmission of records that states are unable to correct.

[1][1] CMS will provide direction at a later date concerning resubmission of records that states are unable to correct.

1 CMS Guidance – Reporting Financial Transactions in T-MSIS – 2014-04-23

2 Business dates represent the date stored in a state’s systems that reflects when a data element value changed. Some states do not store business dates for certain data elements, sometimes because the dates would not affect claim adjudication. For example, if a beneficiary’s enrollment data were updated to correct their sex, the claims processing system will assume that this change should be applied to all claims, regardless of date of service or date of submission.

3 Seven fiscal years of history was selected so that T-MSIS will contain a minimum standard number of years of history across all states. (Note that the 7 years of history – from 1/1/2014 back to 10/1/2006 – is irrespective of the actual date when the state submits its first T-MSIS production file.) If a state has reliable data that go back into history farther than 10/1/2006 and would be willing to submit them, CMS will welcome them.

4 Archived records are those whose data element values are active but which the state considers to be permanently static. (Oftentimes, these records are no longer actively used in the state’s system and are moved to a separate data storage area for long-term retention.) For example, it is very unlikely that a state will receive a claim for a beneficiary that died more than seven years ago. The state might decide to “archive” that beneficiary’s record so that it is not part of the MMIS operational database anymore. After the record is archived, it would no longer be reported in the state’s T-MSIS file, but the record will be maintained in the underlying T-MSIS database.

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