Transformed - Medicaid Statistical Information System (T-MSIS)
Transformed - Medicaid Statistical Information System (T-MSIS) (CMS-R-284)
1-TMSIS_V2.1_DataDictionary (2019 version 2).xlsx
Transformed - Medicaid Statistical Information System (T-MSIS)
OMB: 0938-0345
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0345 can be found here:
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Data Element Definitions, Etc.
Rec Segment Keys & Constraints
Overview
Cover SheetData Element Definitions, Etc.
Rec Segment Keys & Constraints
Sheet 1: Cover Sheet
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| Centers for Medicaid and CHIP Services (CMCS) | ||||||||||
| Transformed Medicaid Statistical Information System | ||||||||||
| (T-MSIS) | ||||||||||
| Data Dictionary | ||||||||||
| Version: Nov07v2.1 | ||||||||||
| Last Modified: 11/7/2017 | ||||||||||
| End of Sheet | ||||||||||
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Sheet 2: Data Element Definitions, Etc.
| V2.1 T-MSIS Data Dictionary | ||||||||||
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| 1 | CIP001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002 | Required | Value must be equal to a valid value. | CIP00001 | 4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP001-0001 |
| 2 | CIP001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP001-0002 |
| 3 | CIP002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP002-0001 |
| 4 | CIP003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP003-0001 |
| 5 | CIP003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 6 | CIP004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or pipe-delimited format | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP004-0001 |
| 7 | CIP005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document | Not Applicable | 2/25/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP005-0001 |
| 8 | CIP006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Value must be equal to a valid value. | CLAIM-IP - Inpatient Claim/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132, or 135. (Note: In CLAIMIP, TYPE-OF-SERVICE 086 and 084 refer only to services received on an inpatient basis.) |
8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP006-0001 |
| 9 | CIP006 | FILE-NAME | Not Applicable | Not Applicable | For TYPE-OF-SERVICE = 001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132, or 135, FILE-NAME must be CLAIM-IP. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 10 | CIP007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP007-0002 |
| 11 | CIP007 | SUBMITTING-STATE | Not Applicable | Not Applicable | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP007-0001 |
| 12 | CIP007 | SUBMITTING-STATE | Not Applicable | Not Applicable | Must be populated on every record. | Not Applicable | 4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP007-0003 |
| 13 | CIP007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP007-0004 |
| 14 | CIP008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP008-0001 |
| 15 | CIP008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP008-0002 |
| 16 | CIP008 | DATE-FILE-CREATED | Not Applicable | NA | Required on every file header | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 17 | CIP008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field. | Not Applicable | 10/10/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP008-0003 |
| 18 | CIP009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP009-0001 |
| 19 | CIP009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 20 | CIP009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP009-0002 |
| 21 | CIP009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 22 | CIP009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 23 | CIP009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 24 | CIP010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP010-0001 |
| 25 | CIP010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP010-0002 |
| 26 | CIP010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 27 | CIP010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 28 | CIP010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than DATE-FILE-CREATED. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 29 | CIP010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be greater than START-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 30 | CIP011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP011-0001 |
| 31 | CIP011 | FILE-STATUS-INDICATOR | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 32 | CIP011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 33 | CIP012 | SSN-INDICATOR | Indicates whether the state uses the eligible person's social security number (SSN) instead of an MSIS identification number as the unique, unchanging eligible person identifier. | Required | Value must be equal to a valid value. | 0 State does not use SSN as MSIS-IDENTIFICATION-NUMBER 1 State uses SSN as MSIS-IDENTIFICATION-NUMBER |
4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP012-0001 |
| 34 | CIP012 | SSN-INDICATOR | Not Applicable | NA | A state's SSN/Non-SSN designation on the eligibility file should match on the claims files. | Not Applicable | 4/30/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP012-0002 |
| 35 | CIP012 | SSN-INDICATOR | Not Applicable | NA | For non-SSN states, the SSN-INDICATOR in the Header record must be set to 0 and the MSIS identification number must be reported in the MSIS-IDENTIFICATION-NUMBER field. If the MSIS-IDENTIFICATION-NUMBER is not known then this field should be 9-filled, left blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 36 | CIP013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP013-0001 |
| 37 | CIP013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable |
| 38 | CIP014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP014-0001 |
| 39 | CIP014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP014-0002 |
| 40 | CIP015 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP015-0001 |
| 41 | CIP016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002. | Required | Value must be equal to a valid value. | CIP00002 | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP016-0001 |
| 42 | CIP016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP016-0002 |
| 43 | CIP017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP017-0001 |
| 44 | CIP017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP017-0002 |
| 45 | CIP017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 46 | CIP017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP017-0004 |
| 47 | CIP018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP018-0001 |
| 48 | CIP018 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP018-0002 |
| 49 | CIP018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP018-0003 |
| 50 | CIP019 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP019-0001 |
| 51 | CIP019 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP019-0002 |
| 52 | CIP019 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP019-0003 |
| 53 | CIP019 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 54 | CIP020 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP020-0001 |
| 55 | CIP020 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP020-0002 |
| 56 | CIP020 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP020-0003 |
| 57 | CIP021 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to the state’s claim adjudication system. |
Conditional | Value must not be null | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP021-0001 |
| 58 | CIP022 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP022-0001 |
| 59 | CIP022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN States, this field must contain an identification number assigned by the State. The format of the State ID numbers must be supplied to CMS. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP022-0002 |
| 60 | CIP022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For TYPE-OF-CLAIM = 4 or D or X (lump sum adjustments), this field must begin with an ‘&’. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP022-0003 |
| 61 | CIP022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN States, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP022-0004 |
| 62 | CIP023 | CROSSOVER-INDICATOR | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Required | Value must be equal to a valid value. | 0 Not Crossover Claim 1 Crossover Claim |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP023-0001 |
| 63 | CIP023 | CROSSOVER-INDICATOR | Not Applicable | NA | If Crossover Indicator is Yes, there must be Medicare enrollment in the Eligible file for the same time period (by date of service). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP023-0002 |
| 64 | CIP023 | CROSSOVER-INDICATOR | Not Applicable | NA | Detail records should be created for all crossover claims. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP023-0003 |
| 65 | CIP024 | TYPE-OF-HOSPITAL | This code denotes the type of hospital on the claim (servicing provider). | Required | Value must be equal to a valid value. | 00 Not of 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP024-0001 |
| 66 | CIP025 | 1115A-DEMONSTRATION-IND | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP025-0001 |
| 67 | CIP026 | ADJUSTMENT-IND | Code indicating the type of adjustment record. | Required | Value must be equal to a valid value. |
0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP026-0001 |
| 68 | CIP026 | ADJUSTMENT-IND | Not Applicable | NA | ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "3", "5", "A", "C", "E", "U", "W", "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP026-0002 |
| 69 | CIP027 | ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP027-0001 |
| 70 | CIP027 | ADJUSTMENT-REASON-CODE | Not Applicable | NA | If there is no adjustment to a claim, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE). If claim record does not represent an adjustment, blank-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP027-0002 |
| 71 | CIP028 | ADMISSION-TYPE | The basic types of admission for Inpatient hospital stays and a code indicating the priority of this admission. | Required | Value must be equal to a valid value. | 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.) 9 UNKNOWN Information not available. |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP028-0001 |
| 72 | CIP028 | ADMISSION-TYPE | Not Applicable | NA | Value as it is reported in FL 14 - Type of Admission/Visit on the UB04 or on Loop 2300 CL1 of the X12 transaction form. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP028-0002 |
| 73 | CIP029 | DRG-DESCRIPTION | Description of the associated state-specific DRG code. If using standard MS-DRG classification system, leave blank |
Conditional | Value must originate from the DRGS list or be blank. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP029-0001 |
| 74 | CIP029 | DRG-DESCRIPTION | Not Applicable | NA | States using the federal code should leave DRG-description blank; otherwise they should use a code that legitimately belongs to their code set. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP029-0002 |
| 75 | CIP030 | ADMITTING-DIAGNOSIS-CODE | The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician. | Required | Code full valid ICD 9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 “. Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP030-0001 |
| 76 | CIP030 | ADMITTING-DIAGNOSIS-CODE | Not Applicable | NA | The diagnosis provided by the physician at the time of admission which describes the patient's condition upon admission to the hospital. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP030-0003 |
| 77 | CIP030 | ADMITTING-DIAGNOSIS-CODE | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP030-0004 |
| 78 | CIP031 | ADMITTING-DIAGNOSIS-CODE-FLAG | A flag that identifies the coding system used for the ADMITTING-DIAGNOSIS-CODE. | Required | Value must be equal to a valid value. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP031-0001 |
| 79 | CIP031 | ADMITTING-DIAGNOSIS-CODE-FLAG | Not Applicable | NA | The state must use a code that belongs to the code set that they report they are using. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP031-0002 |
| 80 | CIP032 | DIAGNOSIS-CODE-1 | The primary/principal ICD-9/10-CM diagnosis code as reported on the claim. | Required | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP032-0001 |
| 81 | CIP032 | DIAGNOSIS-CODE-1 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP032-0002 |
| 82 | CIP032 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP032-0003 |
| 83 | CIP032 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP032-0004 |
| 84 | CIP032 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP032-0005 |
| 85 | CIP032 | DIAGNOSIS-CODE-1 | Not Applicable | NA | The primary/principal diagnosis code goes into DIAGNOSIS-CODE1 | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP032-0006 |
| 86 | CIP032 | DIAGNOSIS-CODE-1 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP032-0007 |
| 87 | CIP033 | DIAGNOSIS-CODE-FLAG-1 | Flag used to identify if DIAGNOSIS-CODE-1 field is reported with ICD-9 or ICD-10 code. | Required | Value must be equal to a valid value. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP033-0001 |
| 88 | CIP033 | DIAGNOSIS-CODE-FLAG-1 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP033-0002 |
| 89 | CIP033 | DIAGNOSIS-CODE-FLAG-1 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP033-0004 |
| 90 | CIP034 | DIAGNOSIS-POA-FLAG-1 | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP034-0001 |
| 91 | CIP034 | DIAGNOSIS-POA-FLAG-1 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP034-0002 |
| 92 | CIP035 | DIAGNOSIS-CODE-2 | The second ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP035-0001 |
| 93 | CIP035 | DIAGNOSIS-CODE-2 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP035-0002 |
| 94 | CIP035 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP035-0003 |
| 95 | CIP035 | DIAGNOSIS-CODE-2 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP035-0004 |
| 96 | CIP035 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP035-0005 |
| 97 | CIP035 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP035-0006 |
| 98 | CIP036 | DIAGNOSIS-CODE-FLAG-2 | Flag used to identify if DIAGNOSIS-CODE-2 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP036-0001 |
| 99 | CIP036 | DIAGNOSIS-CODE-FLAG-2 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP036-0002 |
| 100 | CIP036 | DIAGNOSIS-CODE-FLAG-2 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP036-0004 |
| 101 | CIP037 | DIAGNOSIS-POA-FLAG-2 | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP037-0001 |
| 102 | CIP037 | DIAGNOSIS-POA-FLAG-2 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP037-0002 |
| 103 | CIP038 | DIAGNOSIS-CODE-3 | The third ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP038-0001 |
| 104 | CIP038 | DIAGNOSIS-CODE-3 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP038-0002 |
| 105 | CIP038 | DIAGNOSIS-CODE-3 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP038-0003 |
| 106 | CIP038 | DIAGNOSIS-CODE-3 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP038-0004 |
| 107 | CIP038 | DIAGNOSIS-CODE-3 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP038-0005 |
| 108 | CIP038 | DIAGNOSIS-CODE-3 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP038-0006 |
| 109 | CIP039 | DIAGNOSIS-CODE-FLAG-3 | Flag used to identify if DIAGNOSIS-CODE-3 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP039-0001 |
| 110 | CIP039 | DIAGNOSIS-CODE-FLAG-3 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP039-0002 |
| 111 | CIP039 | DIAGNOSIS-CODE-FLAG-3 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP039-0004 |
| 112 | CIP040 | DIAGNOSIS-POA-FLAG-3 | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP040-0001 |
| 113 | CIP040 | DIAGNOSIS-POA-FLAG-3 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP040-0002 |
| 114 | CIP041 | DIAGNOSIS-CODE-4 | The fourth ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP041-0001 |
| 115 | CIP041 | DIAGNOSIS-CODE-4 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP041-0002 |
| 116 | CIP041 | DIAGNOSIS-CODE-4 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP041-0003 |
| 117 | CIP041 | DIAGNOSIS-CODE-4 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP041-0004 |
| 118 | CIP041 | DIAGNOSIS-CODE-4 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP041-0005 |
| 119 | CIP041 | DIAGNOSIS-CODE-4 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP041-0006 |
| 120 | CIP042 | DIAGNOSIS-CODE-FLAG-4 | Flag used to identify if DIAGNOSIS-CODE-4 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP042-0001 |
| 121 | CIP042 | DIAGNOSIS-CODE-FLAG-4 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP042-0002 |
| 122 | CIP042 | DIAGNOSIS-CODE-FLAG-4 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP042-0004 |
| 123 | CIP043 | DIAGNOSIS-POA-FLAG-4 | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP043-0001 |
| 124 | CIP043 | DIAGNOSIS-POA-FLAG-4 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP043-0002 |
| 125 | CIP044 | DIAGNOSIS-CODE-5 | The fifth ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP044-0001 |
| 126 | CIP044 | DIAGNOSIS-CODE-5 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP044-0002 |
| 127 | CIP044 | DIAGNOSIS-CODE-5 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP044-0003 |
| 128 | CIP044 | DIAGNOSIS-CODE-5 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP044-0004 |
| 129 | CIP044 | DIAGNOSIS-CODE-5 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP044-0005 |
| 130 | CIP044 | DIAGNOSIS-CODE-5 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP044-0006 |
| 131 | CIP045 | DIAGNOSIS-CODE-FLAG-5 | Flag used to identify if DIAGNOSIS-CODE-5 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP045-0001 |
| 132 | CIP045 | DIAGNOSIS-CODE-FLAG-5 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP045-0002 |
| 133 | CIP045 | DIAGNOSIS-CODE-FLAG-5 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP045-0004 |
| 134 | CIP046 | DIAGNOSIS-POA-FLAG-5 | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP046-0001 |
| 135 | CIP046 | DIAGNOSIS-POA-FLAG-5 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP046-0002 |
| 136 | CIP047 | DIAGNOSIS-CODE-6 | The sixth ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP047-0001 |
| 137 | CIP047 | DIAGNOSIS-CODE-6 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP047-0002 |
| 138 | CIP047 | DIAGNOSIS-CODE-6 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP047-0003 |
| 139 | CIP047 | DIAGNOSIS-CODE-6 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP047-0004 |
| 140 | CIP047 | DIAGNOSIS-CODE-6 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP047-0005 |
| 141 | CIP047 | DIAGNOSIS-CODE-6 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP047-0006 |
| 142 | CIP048 | DIAGNOSIS-CODE-FLAG-6 | Flag used to identify if DIAGNOSIS-CODE-6 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP048-0001 |
| 143 | CIP048 | DIAGNOSIS-CODE-FLAG-6 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP048-0002 |
| 144 | CIP048 | DIAGNOSIS-CODE-FLAG-6 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP048-0004 |
| 145 | CIP049 | DIAGNOSIS-POA-FLAG-6 | A flag that indicates “Present on Admission” for DIAGNOSIS CODE 1 - 12. A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP049-0001 |
| 146 | CIP049 | DIAGNOSIS-POA-FLAG-6 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP049-0002 |
| 147 | CIP050 | DIAGNOSIS-CODE-7 | The seventh ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP050-0001 |
| 148 | CIP050 | DIAGNOSIS-CODE-7 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP050-0002 |
| 149 | CIP050 | DIAGNOSIS-CODE-7 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP050-0003 |
| 150 | CIP050 | DIAGNOSIS-CODE-7 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP050-0004 |
| 151 | CIP050 | DIAGNOSIS-CODE-7 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP050-0005 |
| 152 | CIP050 | DIAGNOSIS-CODE-7 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP050-0006 |
| 153 | CIP051 | DIAGNOSIS-CODE-FLAG-7 | Flag used to identify if DIAGNOSIS-CODE-7 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP051-0001 |
| 154 | CIP051 | DIAGNOSIS-CODE-FLAG-7 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP051-0002 |
| 155 | CIP051 | DIAGNOSIS-CODE-FLAG-7 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP051-0004 |
| 156 | CIP052 | DIAGNOSIS-POA-FLAG-7 | A flag that indicates “Present on Admission” for DIAGNOSIS CODE 1 - 12. A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP052-0001 |
| 157 | CIP052 | DIAGNOSIS-POA-FLAG-7 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP052-0002 |
| 158 | CIP053 | DIAGNOSIS-CODE-8 | The eighth ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP053-0001 |
| 159 | CIP053 | DIAGNOSIS-CODE-8 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP053-0002 |
| 160 | CIP053 | DIAGNOSIS-CODE-8 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP053-0003 |
| 161 | CIP053 | DIAGNOSIS-CODE-8 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP053-0004 |
| 162 | CIP053 | DIAGNOSIS-CODE-8 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP053-0005 |
| 163 | CIP053 | DIAGNOSIS-CODE-8 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP053-0006 |
| 164 | CIP054 | DIAGNOSIS-CODE-FLAG-8 | Flag used to identify if DIAGNOSIS-CODE-8 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP054-0001 |
| 165 | CIP054 | DIAGNOSIS-CODE-FLAG-8 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP054-0002 |
| 166 | CIP054 | DIAGNOSIS-CODE-FLAG-8 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP054-0004 |
| 167 | CIP055 | DIAGNOSIS-POA-FLAG-8 | A flag that indicates “Present on Admission” for DIAGNOSIS CODE 1 - 12. A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP055-0001 |
| 168 | CIP055 | DIAGNOSIS-POA-FLAG-8 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP055-0002 |
| 169 | CIP056 | DIAGNOSIS-CODE-9 | The ninth ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP056-0001 |
| 170 | CIP056 | DIAGNOSIS-CODE-9 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP056-0002 |
| 171 | CIP056 | DIAGNOSIS-CODE-9 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP056-0003 |
| 172 | CIP056 | DIAGNOSIS-CODE-9 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP056-0004 |
| 173 | CIP056 | DIAGNOSIS-CODE-9 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP056-0005 |
| 174 | CIP056 | DIAGNOSIS-CODE-9 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP056-0006 |
| 175 | CIP057 | DIAGNOSIS-CODE-FLAG-9 | Flag used to identify if DIAGNOSIS-CODE-9 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP057-0001 |
| 176 | CIP057 | DIAGNOSIS-CODE-FLAG-9 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP057-0002 |
| 177 | CIP057 | DIAGNOSIS-CODE-FLAG-9 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP057-0004 |
| 178 | CIP058 | DIAGNOSIS-POA-FLAG-9 | A flag that indicates “Present on Admission” for DIAGNOSIS CODE 1 - 12. A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. All UNUSED diagnosis and occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP058-0001 |
| 179 | CIP058 | DIAGNOSIS-POA-FLAG-9 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP058-0002 |
| 180 | CIP059 | DIAGNOSIS-CODE-10 | The tenth ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP059-0001 |
| 181 | CIP059 | DIAGNOSIS-CODE-10 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP059-0002 |
| 182 | CIP059 | DIAGNOSIS-CODE-10 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP059-0003 |
| 183 | CIP059 | DIAGNOSIS-CODE-10 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP059-0004 |
| 184 | CIP059 | DIAGNOSIS-CODE-10 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP059-0005 |
| 185 | CIP059 | DIAGNOSIS-CODE-10 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP059-0006 |
| 186 | CIP060 | DIAGNOSIS-CODE-FLAG-10 | Flag used to identify if DIAGNOSIS-CODE-10 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP060-0001 |
| 187 | CIP060 | DIAGNOSIS-CODE-FLAG-10 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP060-0002 |
| 188 | CIP060 | DIAGNOSIS-CODE-FLAG-10 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP060-0004 |
| 189 | CIP061 | DIAGNOSIS-POA-FLAG-10 | A flag that indicates “Present on Admission” for DIAGNOSIS CODE 1 - 12. A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP061-0001 |
| 190 | CIP061 | DIAGNOSIS-POA-FLAG-10 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP061-0002 |
| 191 | CIP062 | DIAGNOSIS-CODE-11 | The eleventh ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP062-0001 |
| 192 | CIP062 | DIAGNOSIS-CODE-11 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP062-0002 |
| 193 | CIP062 | DIAGNOSIS-CODE-11 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP062-0003 |
| 194 | CIP062 | DIAGNOSIS-CODE-11 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP062-0004 |
| 195 | CIP062 | DIAGNOSIS-CODE-11 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP062-0005 |
| 196 | CIP062 | DIAGNOSIS-CODE-11 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP062-0006 |
| 197 | CIP063 | DIAGNOSIS-CODE-FLAG-11 | Flag used to identify if DIAGNOSIS-CODE-11 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP063-0001 |
| 198 | CIP063 | DIAGNOSIS-CODE-FLAG-11 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP063-0002 |
| 199 | CIP063 | DIAGNOSIS-CODE-FLAG-11 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP063-0004 |
| 200 | CIP064 | DIAGNOSIS-POA-FLAG-11 | A flag that indicates “Present on Admission” for DIAGNOSIS CODE 1 - 12. A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP064-0001 |
| 201 | CIP064 | DIAGNOSIS-POA-FLAG-11 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP064-0002 |
| 202 | CIP065 | DIAGNOSIS-CODE-12 | The twelfth ICD-9/10-CM diagnosis code as reported on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP065-0001 |
| 203 | CIP065 | DIAGNOSIS-CODE-12 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP065-0002 |
| 204 | CIP065 | DIAGNOSIS-CODE-12 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP065-0003 |
| 205 | CIP065 | DIAGNOSIS-CODE-12 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP065-0004 |
| 206 | CIP065 | DIAGNOSIS-CODE-12 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not blank-fill, 8-fill or 9-fill these items | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP065-0005 |
| 207 | CIP065 | DIAGNOSIS-CODE-12 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP065-0006 |
| 208 | CIP066 | DIAGNOSIS-CODE-FLAG-12 | Flag used to identify if DIAGNOSIS-CODE-12 field is reported with ICD-9 or ICD-10 code. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP066-0001 |
| 209 | CIP066 | DIAGNOSIS-CODE-FLAG-12 | Not Applicable | NA | For implementation date edits, Ending Date of Service will be used for IP. This is to be in alignment with the Medicare requirements. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP066-0002 |
| 210 | CIP066 | DIAGNOSIS-CODE-FLAG-12 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP066-0004 |
| 211 | CIP067 | DIAGNOSIS-POA-FLAG-12 | A flag that indicates “Present on Admission” for DIAGNOSIS CODE 1 - 12. A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP067-0001 |
| 212 | CIP067 | DIAGNOSIS-POA-FLAG-12 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP067-0002 |
| 213 | CIP068 | DIAGNOSIS-RELATED-GROUP | Code representing the Diagnosis Related Group (DRG) that is applicable for the inpatient services being rendered. | Conditional | Enter the DRG used by the state for FFS claims or the DRG used by the managed care plan for managed care encounters. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP068-0001 |
| 214 | CIP068 | DIAGNOSIS-RELATED-GROUP | Not Applicable | NA | If DRGs are not used, blank-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP068-0002 |
| 215 | CIP068 | DIAGNOSIS-RELATED-GROUP | Not Applicable | NA | This field should only be reported on FFS claims and encounters records in which diagnosis related groups are used to determine paid amounts. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP068-0003 |
| 216 | CIP069 | DIAGNOSIS-RELATED-GROUP-IND | An indicator identifying the grouping algorithm used to assign Diagnosis Related Group (DRG) values. | Conditional | Values are generated by combining two types of information: Position 1-2, State/Group generating DRG: If state specific system, fill with two digit US postal code representation for state. If CMS Grouper, fill with “HG”. If any other system, fill with “XX”. Position 3-4, fill with the number that represents the DRG version used (01-98). For example, “HG15" would represent CMS Grouper version 15. If version is unknown, fill with “99". |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP069-0001 |
| 217 | CIP069 | DIAGNOSIS-RELATED-GROUP-IND | Not Applicable | NA | If Value is unknown,leave blank, or space-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP069-0002 |
| 218 | CIP069 | DIAGNOSIS-RELATED-GROUP-IND | Not Applicable | NA | This field is required if DIAGNOSIS-RELATED-GROUP is populated. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP069-0003 |
| 219 | CIP069 | DIAGNOSIS-RELATED-GROUP-IND | Not Applicable | NA | If a non-DRG paying state, report the field as blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP069-0007 |
| 220 | CIP070 | PROCEDURE-CODE-1 | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-MOD-1, PROCEDURE-CODE-DATE-1, and PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
Conditional | Value must be equal to a valid value. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP070-0001 |
| 221 | CIP070 | PROCEDURE-CODE-1 | Not Applicable | NA | If PROCDURE-CODE-FLAG-1 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats: | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP070-0002 |
| 222 | CIP071 | PROCEDURE-CODE-MOD-1 | The procedure code modifier used with the (Principal) Procedure Code 1. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. | NA | If no Principal Procedure (procedure-code-1) was performed, space-fill | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP071-0001 |
| 223 | CIP071 | PROCEDURE-CODE-MOD-1 | Not Applicable | NA | Value must be blank if corresponding procedure code is blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP071-0002 |
| 224 | CIP071 | PROCEDURE-CODE-MOD-1 | Not Applicable | NA | Always leave blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). Modifiers do not exist for ICD-9/10 procedure codes for claims/encounters and will never be applicable. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP071-0003 |
| 225 | CIP071 | PROCEDURE-CODE-MOD-1 | Not Applicable | NA | Not Applicable | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP071-0004 |
| 226 | CIP072 | PROCEDURE-CODE-FLAG-1 | A flag that identifies the coding system used for PROCDURE-CODE-1. | Conditional | Value must be equal to a valid value. | 01 CPT 4 02 ICD-9 CM 06 HCPCS (Both National and Regional HCPCS) 07 ICD-10-PCS (Will be implemented on 10/1/2014) 10-87 Other Systems |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP072-0001 |
| 227 | CIP072 | PROCEDURE-CODE-FLAG-1 | Not Applicable | NA | If no Principal Procedure (procedure-code-1) was performed, leave blank | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP072-0002 |
| 228 | CIP073 | PROCEDURE-CODE-DATE-1 | The date upon which the PROCEDURE-CODE-1 was performed. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP073-0001 |
| 229 | CIP073 | PROCEDURE-CODE-DATE-1 | Not Applicable | NA | Value must be a valid date | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP073-0002 |
| 230 | CIP073 | PROCEDURE-CODE-DATE-1 | Not Applicable | NA | If the corresponding procedure code is 8-filled, left blank or space-filled then this procedure code date must be left blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP073-0003 |
| 231 | CIP073 | PROCEDURE-CODE-DATE-1 | Not Applicable | NA | Date must occur before the ENDING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP073-0004 |
| 232 | CIP073 | PROCEDURE-CODE-DATE-1 | Not Applicable | NA | Date must occur on or after the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP073-0005 |
| 233 | CIP073 | PROCEDURE-CODE-DATE-1 | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible file. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP073-0006 |
| 234 | CIP074 | PROCEDURE-CODE-2 | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-MOD-1, PROCEDURE-CODE-DATE-1, and PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
Conditional | Value must be equal to a valid value. | 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. |
10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0001 |
| 235 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | Enter as many procedures as are reported after the principal procedure up to five additional codes. Remaining fields should be 8-filled, left blank or space-filled (e.g., if claim contains two additional procedures, they would be reported in PROCDURE-CODE-2 and PROCDURE-CODE-3. Remaining fields PROCDURE-CODE-4 through PROCDURE-CODE-6 would all be left blank or space-filled.) | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0002 |
| 236 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | If PROCDURE-CODE-FLAG-2 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats: | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0003 |
| 237 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | o ICD-9/10-CM (corresponding PROCEDURE-CODE-FLAG = 02/07): Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-8 must be blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0004 |
| 238 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | Value can include both National and Local (Regional) codes. For National codes (position 1=“A”-“V”) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234"). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0005 |
| 239 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | If no PROCEDURE-CODE-2 was performed, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0006 |
| 240 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | Note: An eighth character is provided for future expansion of this field. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0007 |
| 241 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | If the corresponding procedure code flag is 8-filled, left blank or space-filled, then this procedure code should be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0008 |
| 242 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | If the corresponding procedure code flag is not 8-filled, left blank or space-filled, then this procedure code must not be 8- filled, blank or space-filled | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0009 |
| 243 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | Value must be different from the preceding procedure code values. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0010 |
| 244 | CIP074 | PROCEDURE-CODE-2 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE if the preceding PROCEDURE-CODE element is not populated. (i.e. if PROCEDURE-CODE-2 is populated, but PROCEDURE-CODE-3 is blank-filled, then PROCEDURE-CODE-4 must also not be valued. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP074-0011 |
| 245 | CIP075 | PROCEDURE-CODE-MOD-2 | A series of procedure code modifiers used with the corresponding Procedure Codes. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. |
NA | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP075-0001 |
| 246 | CIP075 | PROCEDURE-CODE-MOD-2 | Not Applicable | NA | Value must be left blank or space-filled if corresponding procedure code is blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP075-0002 |
| 247 | CIP075 | PROCEDURE-CODE-MOD-2 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP075-0003 |
| 248 | CIP075 | PROCEDURE-CODE-MOD-2 | Not Applicable | NA | Always leave blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). Modifiers do not exist for ICD-9/10 procedure codes for claims/encounters and will never be applicable. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP075-0004 |
| 249 | CIP075 | PROCEDURE-CODE-MOD-2 | Not Applicable | NA | Not Applicable | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP075-0005 |
| 250 | CIP076 | PROCEDURE-CODE-FLAG-2 | A series of flags that identifies the coding system used for the associated procedure codes (PROCDURE-CODE-2 through PROCDURE-CODE-6) | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP076-0001 |
| 251 | CIP076 | PROCEDURE-CODE-FLAG-2 | Not Applicable | NA | If no second procedure was performed, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP076-0002 |
| 252 | CIP076 | PROCEDURE-CODE-FLAG-2 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-FLAG if the preceding PROCEDURE-CODE-FLAG element is not populated. (i.e. if PROCEDURE-CODE-FLAG-2 is populated, but PROCEDURE-CODE-FLAG-3 is blank-filled, then PROCEDURE-CODE-FLAG-4 must also not be valued. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP076-0003 |
| 253 | CIP077 | PROCEDURE-CODE-DATE-2 | The date on which the procedure 2 – 6 was performed. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP077-0001 |
| 254 | CIP077 | PROCEDURE-CODE-DATE-2 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP077-0002 |
| 255 | CIP077 | PROCEDURE-CODE-DATE-2 | Not Applicable | NA | If the corresponding procedure code is left blank or space-filled, then this procedure code date must be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP077-0003 |
| 256 | CIP077 | PROCEDURE-CODE-DATE-2 | Not Applicable | NA | Date must occur before the ENDING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP077-0004 |
| 257 | CIP077 | PROCEDURE-CODE-DATE-2 | Not Applicable | NA | Date must occur on or after the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP077-0005 |
| 258 | CIP078 | PROCEDURE-CODE-3 | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-MOD-1, PROCEDURE-CODE-DATE-1, and PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
Conditional | Enter as many procedures as are reported after the principal procedure up to five additional codes. Remaining fields should be left blank or space-filled (e.g., if claim contains two additional procedures, they would be reported in PROCDURE-CODE-2 and PROCDURE-CODE-3. Remaining fields PROCDURE-CODE-4 through PROCDURE-CODE-6 would all be blank or space-filled.) | 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. |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0001 |
| 259 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | Value must be equal to a valid value. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0002 |
| 260 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | If PROCDURE-CODE-FLAG-3 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats: | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0003 |
| 261 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | o ICD-9/10-CM (corresponding PROCEDURE-CODE-FLAG = 02/07): Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-8 must be blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0004 |
| 262 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | Value can include both National and Local (Regional) codes. For National codes (position 1=“A”-“V”) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234"). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0005 |
| 263 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | If no PROCEDURE-CODE-3 was performed, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0006 |
| 264 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | Note: An eighth character is provided for future expansion of this field. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0007 |
| 265 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | If the corresponding procedure code flag is left blank or space-filled, then this procedure code should be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0008 |
| 266 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | If the corresponding procedure code flag is not 8-filled, left blank or space-filled, then this procedure code must not be 8- filled, blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0009 |
| 267 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | Value must be different from the preceding procedure code values. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0010 |
| 268 | CIP078 | PROCEDURE-CODE-3 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE if the preceding PROCEDURE-CODE element is not populated. (i.e. if PROCEDURE-CODE-2 is populated, but PROCEDURE-CODE-3 is blank-filled, then PROCEDURE-CODE-4 must also not be valued. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP078-0011 |
| 269 | CIP079 | PROCEDURE-CODE-MOD-3 | A series of procedure code modifiers used with the corresponding Procedure Codes. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. |
NA | Value must be left blank or space-filled if corresponding procedure code is blank or space-filled. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP079-0001 |
| 270 | CIP079 | PROCEDURE-CODE-MOD-3 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP079-0002 |
| 271 | CIP079 | PROCEDURE-CODE-MOD-3 | Not Applicable | NA | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP079-0003 |
| 272 | CIP079 | PROCEDURE-CODE-MOD-3 | Not Applicable | NA | Always leave blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). Modifiers do not exist for ICD-9/10 procedure codes for claims/encounters and will never be applicable. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP079-0004 |
| 273 | CIP079 | PROCEDURE-CODE-MOD-3 | Not Applicable | NA | Not Applicable | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP079-0005 |
| 274 | CIP080 | PROCEDURE-CODE-FLAG-3 | A series of flags that identifies the coding system used for the associated procedure codes (PROCDURE-CODE-2 through PROCDURE-CODE-6) | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP080-0001 |
| 275 | CIP080 | PROCEDURE-CODE-FLAG-3 | Not Applicable | NA | If no third procedure was performed, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP080-0002 |
| 276 | CIP080 | PROCEDURE-CODE-FLAG-3 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-FLAG if the preceding PROCEDURE-CODE-FLAG element is not populated. (i.e. if PROCEDURE-CODE-FLAG-2 is populated, but PROCEDURE-CODE-FLAG-3 is blank-filled, then PROCEDURE-CODE-FLAG-4 must also not be valued. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP080-0003 |
| 277 | CIP081 | PROCEDURE-CODE-DATE-3 | The date on which the procedure 2 – 6 was performed |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP081-0001 |
| 278 | CIP081 | PROCEDURE-CODE-DATE-3 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP081-0002 |
| 279 | CIP081 | PROCEDURE-CODE-DATE-3 | Not Applicable | NA | If the corresponding procedure code is left blank or space-filled, then this procedure code date must be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP081-0003 |
| 280 | CIP081 | PROCEDURE-CODE-DATE-3 | Not Applicable | NA | Date must occur before the ENDING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP081-0004 |
| 281 | CIP081 | PROCEDURE-CODE-DATE-3 | Not Applicable | NA | Date must occur on or after the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP081-0005 |
| 282 | CIP081 | PROCEDURE-CODE-DATE-3 | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible file. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP081-0006 |
| 283 | CIP081 | PROCEDURE-CODE-DATE-3 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-DATE if the preceding PROCEDURE-CODE-DATE element is not populated. (i.e. if PROCEDURE-CODE-DATE-2 is populated, but PROCEDURE-CODE-DATE-3 is blank-filled, then PROCEDURE-CODE-DATE-4 must also not be valued. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP081-0007 |
| 284 | CIP082 | PROCEDURE-CODE-4 | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-MOD-1, PROCEDURE-CODE-DATE-1, and PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
Conditional | Enter as many procedures as are reported after the principal procedure up to five additional codes. Remaining fields should be 8-filled, left blank or space-filled (e.g., if claim contains two additional procedures, they would be reported in PROCDURE-CODE-2 and PROCDURE-CODE-3. Remaining fields PROCDURE-CODE-4 through PROCDURE-CODE-6 would all be left blank or space-filled.) | 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. |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0001 |
| 285 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | Value must be equal to a valid value. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0002 |
| 286 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | If PROCDURE-CODE-FLAG-1 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats: | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0003 |
| 287 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | o ICD-9/10-CM (corresponding PROCEDURE-CODE-FLAG = 02/07): Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-8 must be blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0004 |
| 288 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | Value can include both National and Local (Regional) codes. For National codes (position 1=“A”-“V”) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234"). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0005 |
| 289 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | If no PROCEDURE-CODE-4 was performed, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0006 |
| 290 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | Note: An eighth character is provided for future expansion of this field. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0007 |
| 291 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | If PROCEDURE-CODE-2 AND PROCEDURE-CODE-3 is left blank or space-filled, then PROCEDURE-CODE-4 must be left blabk or space-filled. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0008 |
| 292 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE if the preceding PROCEDURE-CODE element is not populated. (i.e. if PROCEDURE-CODE-2 is populated, but PROCEDURE-CODE-3 is blank-filled, then PROCEDURE-CODE-4 must also not be valued. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0009 |
| 293 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | If the corresponding procedure code flag is left blank or space-filled then this procedure code should be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0010 |
| 294 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | If the corresponding procedure code flag is not blank or space-filled, then this procedure code should not be 8- filled, blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0011 |
| 295 | CIP082 | PROCEDURE-CODE-4 | Not Applicable | NA | Value must be different from the preceding procedure code values. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP082-0012 |
| 296 | CIP083 | PROCEDURE-CODE-MOD-4 | A series of procedure code modifiers used with the corresponding Procedure Codes. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. |
NA | Value must be left blank or space-filled, if corresponding procedure code is blank or space-filled. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP083-0001 |
| 297 | CIP083 | PROCEDURE-CODE-MOD-4 | Not Applicable | NA | If the corresponding procedure code flag is not left blank or space-filled, then this procedure code must not be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP083-0002 |
| 298 | CIP083 | PROCEDURE-CODE-MOD-4 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP083-0003 |
| 299 | CIP083 | PROCEDURE-CODE-MOD-4 | Not Applicable | NA | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP083-0004 |
| 300 | CIP083 | PROCEDURE-CODE-MOD-4 | Not Applicable | NA | Always leave blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). Modifiers do not exist for ICD-9/10 procedure codes for claims/encounters and will never be applicable. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP083-0005 |
| 301 | CIP083 | PROCEDURE-CODE-MOD-4 | Not Applicable | NA | Not Applicable | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP083-0006 |
| 302 | CIP084 | PROCEDURE-CODE-FLAG-4 | A series of flags that identifies the coding system used for the associated procedure codes (PROCDURE-CODE-2 through PROCDURE-CODE-6) | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP084-0001 |
| 303 | CIP084 | PROCEDURE-CODE-FLAG-4 | Not Applicable | NA | If no fourth procedure was performed, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP084-0002 |
| 304 | CIP084 | PROCEDURE-CODE-FLAG-4 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-FLAG if the preceding PROCEDURE-CODE-FLAG element is not populated. (i.e. if PROCEDURE-CODE-FLAG-2 is populated, but PROCEDURE-CODE-FLAG-3 is blank-filled, then PROCEDURE-CODE-FLAG-4 must also not be valued. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP084-0003 |
| 305 | CIP085 | PROCEDURE-CODE-DATE-4 | The date on which the procedure 2 – 6 was performed |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP085-0001 |
| 306 | CIP085 | PROCEDURE-CODE-DATE-4 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP085-0002 |
| 307 | CIP085 | PROCEDURE-CODE-DATE-4 | Not Applicable | NA | If the corresponding procedure code is left blank or space-filled, then this procedure code date must be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP085-0003 |
| 308 | CIP085 | PROCEDURE-CODE-DATE-4 | Not Applicable | NA | Date must occur before the ENDING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP085-0004 |
| 309 | CIP085 | PROCEDURE-CODE-DATE-4 | Not Applicable | NA | Date must occur on or after the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP085-0005 |
| 310 | CIP085 | PROCEDURE-CODE-DATE-4 | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible file. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP085-0006 |
| 311 | CIP086 | PROCEDURE-CODE-5 | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-MOD-1, PROCEDURE-CODE-DATE-1, and PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
Conditional | Enter as many procedures as are reported after the principal procedure up to five additional codes. Remaining fields should be left blank or space-filled (e.g., if claim contains two additional procedures, they would be reported in PROCDURE-CODE-2 and PROCDURE-CODE-3. Remaining fields PROCDURE-CODE-4 through PROCDURE-CODE-6 would all be left blank or space-filled.) | 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. |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0001 |
| 312 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | Value must be equal to a valid value. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0002 |
| 313 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | If PROCDURE-CODE-FLAG-1 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats: | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0003 |
| 314 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | o ICD-9/10-CM (corresponding PROCEDURE-CODE-FLAG = 02/07): Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-8 must be blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0004 |
| 315 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | Value can include both National and Local (Regional) codes. For National codes (position 1=“A”-“V”) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234"). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0005 |
| 316 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | If no PROCEDURE-CODE-5 was performed, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0006 |
| 317 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | Note: An eighth character is provided for future expansion of this field. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0007 |
| 318 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE if the preceding PROCEDURE-CODE element is not populated. (i.e. if PROCEDURE-CODE-2 is populated, but PROCEDURE-CODE-3 is blank-filled, then PROCEDURE-CODE-4 must also not be valued. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0008 |
| 319 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | If the corresponding procedure code flag is left blank or space-filled, then this procedure code should be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0009 |
| 320 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | If the corresponding procedure code flag is not 8-filled, left blank or space-filled, then this procedure code must not be 8- filled, blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0010 |
| 321 | CIP086 | PROCEDURE-CODE-5 | Not Applicable | NA | Value must be different from the preceding procedure code values. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP086-0011 |
| 322 | CIP087 | PROCEDURE-CODE-MOD-5 | A series of procedure code modifiers used with the corresponding Procedure Codes. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. |
NA | Value must be left blank, or space-filled if corresponding procedure code is blank or space-filled. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP087-0001 |
| 323 | CIP087 | PROCEDURE-CODE-MOD-5 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP087-0002 |
| 324 | CIP087 | PROCEDURE-CODE-MOD-5 | Not Applicable | NA | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP087-0003 |
| 325 | CIP087 | PROCEDURE-CODE-MOD-5 | Not Applicable | NA | Always leave blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). Modifiers do not exist for ICD-9/10 procedure codes for claims/encounters and will never be applicable. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP087-0004 |
| 326 | CIP087 | PROCEDURE-CODE-MOD-5 | Not Applicable | NA | Not Applicable | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP087-0005 |
| 327 | CIP088 | PROCEDURE-CODE-FLAG-5 | A series of flags that identifies the coding system used for the associated procedure codes (PROCDURE-CODE-2 through PROCDURE-CODE-6) | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP088-0001 |
| 328 | CIP088 | PROCEDURE-CODE-FLAG-5 | Not Applicable | NA | If no fifth procedure was performed, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP088-0002 |
| 329 | CIP088 | PROCEDURE-CODE-FLAG-5 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-FLAG if the preceding PROCEDURE-CODE-FLAG element is not populated. (i.e. if PROCEDURE-CODE-FLAG-2 is populated, but PROCEDURE-CODE-FLAG-3 is blank-filled, then PROCEDURE-CODE-FLAG-4 must also not be valued. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP088-0003 |
| 330 | CIP089 | PROCEDURE-CODE-DATE-5 | The date on which the procedure 2 – 6 was performed. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP089-0001 |
| 331 | CIP089 | PROCEDURE-CODE-DATE-5 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP089-0002 |
| 332 | CIP089 | PROCEDURE-CODE-DATE-5 | Not Applicable | NA | If the corresponding procedure code is 8-filled, left blank or space-filled, then this procedure code date must be 8-filled, blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP089-0003 |
| 333 | CIP089 | PROCEDURE-CODE-DATE-5 | Not Applicable | NA | Date must occur before the ENDING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP089-0004 |
| 334 | CIP089 | PROCEDURE-CODE-DATE-5 | Not Applicable | NA | Date must occur on or after the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP089-0005 |
| 335 | CIP089 | PROCEDURE-CODE-DATE-5 | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible file. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP089-0006 |
| 336 | CIP090 | PROCEDURE-CODE-6 | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-MOD-1, PROCEDURE-CODE-DATE-1, and PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
Conditional | Enter as many procedures as are reported after the principal procedure up to five additional codes. Remaining fields should be 8-filled, left blank or space-filled (e.g., if claim contains two additional procedures, they would be reported in PROCDURE-CODE-2 and PROCDURE-CODE-3. Remaining fields PROCDURE-CODE-4 through PROCDURE-CODE-6 would all be left blank or space-filled.) | 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. |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0001 |
| 337 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | Value must be equal to a valid value. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0002 |
| 338 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | If PROCDURE-CODE-FLAG-1 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats: | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0003 |
| 339 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | o ICD-9/10-CM (corresponding PROCEDURE-CODE-FLAG = 02/07): Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-8 must be blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0004 |
| 340 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | Value can include both National and Local (Regional) codes. For National codes (position 1=“A”-“V”) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234"). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0005 |
| 341 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | If no PROCEDURE-CODE-6 was performed, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0006 |
| 342 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | Note: An eighth character is provided for future expansion of this field. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0007 |
| 343 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE if the preceding PROCEDURE-CODE element is not populated. (i.e. if PROCEDURE-CODE-2 is populated, but PROCEDURE-CODE-3 is blank-filled, then PROCEDURE-CODE-4 must also not be valued. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0008 |
| 344 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | If the corresponding procedure code flag is left blank or space-filled, then this procedure code should be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0009 |
| 345 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | If the corresponding procedure code flag is not 8-filled, left blank or space-filled, then this procedure code must not be 8- filled, blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0010 |
| 346 | CIP090 | PROCEDURE-CODE-6 | Not Applicable | NA | Value must be different from the preceding procedure code values. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP090-0011 |
| 347 | CIP091 | PROCEDURE-CODE-MOD-6 | A series of procedure code modifiers used with the corresponding Procedure Codes. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. |
NA | Value must be left blank, or space-filled if corresponding procedure code is blank or space-filled. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP091-0001 |
| 348 | CIP091 | PROCEDURE-CODE-MOD-6 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP091-0002 |
| 349 | CIP091 | PROCEDURE-CODE-MOD-6 | Not Applicable | NA | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP091-0003 |
| 350 | CIP091 | PROCEDURE-CODE-MOD-6 | Not Applicable | NA | Always leave blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). Modifiers do not exist for ICD-9/10 procedure codes for claims/encounters and will never be applicable. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP091-0004 |
| 351 | CIP091 | PROCEDURE-CODE-MOD-6 | Not Applicable | NA | Not Applicable | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP091-0005 |
| 352 | CIP092 | PROCEDURE-CODE-FLAG-6 | A series of flags that identifies the coding system used for the associated procedure codes (PROCDURE-CODE-2 through PROCDURE-CODE-6) | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP092-0001 |
| 353 | CIP092 | PROCEDURE-CODE-FLAG-6 | Not Applicable | NA | If no sixth procedure was performed, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP092-0002 |
| 354 | CIP092 | PROCEDURE-CODE-FLAG-6 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-FLAG if the preceding PROCEDURE-CODE-FLAG element is not populated. (i.e. if PROCEDURE-CODE-FLAG-2 is populated, but PROCEDURE-CODE-FLAG-3 is blank-filled, then PROCEDURE-CODE-FLAG-4 must also not be valued. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP092-0003 |
| 355 | CIP092 | PROCEDURE-CODE-FLAG-6 | Not Applicable | NA | Value must be blank or space-filled if there are no MEDICAID-COV-INPATIENT-DAYS. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP092-0004 |
| 356 | CIP093 | PROCEDURE-CODE-DATE-6 | The date on which the procedure 2 – 6 was performed. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP093-0001 |
| 357 | CIP093 | PROCEDURE-CODE-DATE-6 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP093-0002 |
| 358 | CIP093 | PROCEDURE-CODE-DATE-6 | Not Applicable | NA | If the corresponding procedure code is blank or space-filled, then this procedure code date must be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP093-0003 |
| 359 | CIP093 | PROCEDURE-CODE-DATE-6 | Not Applicable | NA | Date must occur before the ENDING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP093-0004 |
| 360 | CIP093 | PROCEDURE-CODE-DATE-6 | Not Applicable | NA | Date must occur on or after the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP093-0005 |
| 361 | CIP093 | PROCEDURE-CODE-DATE-6 | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible file. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP093-0006 |
| 362 | CIP094 | ADMISSION-DATE | The date on which the recipient was admitted to a hospital. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP094-0001 |
| 363 | CIP094 | ADMISSION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP094-0002 |
| 364 | CIP094 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or before the ADJUDICATION-DATE | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP094-0003 |
| 365 | CIP094 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or before the DISCHARGE-DATE | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP094-0004 |
| 366 | CIP094 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or after the DATE-OF-BIRTH listed in Eligible Record. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP094-0005 |
| 367 | CIP094 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or before the DATE-OF-DEATH listed in Eligible Record. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP094-0006 |
| 368 | CIP095 | ADMISSION-HOUR | The time of admission to a hospital. | Conditional | Value must be a valid hour in military time format (00 to 23). | See Appendix A for listing of valid values. | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP095-0001 |
| 369 | CIP096 | DISCHARGE-DATE | The date on which the recipient was discharged from a hospital. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP096-0001 |
| 370 | CIP096 | DISCHARGE-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP096-0002 |
| 371 | CIP096 | DISCHARGE-DATE | Not Applicable | NA | If a complete, valid date of discharge is not available or is unknown, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP096-0003 |
| 372 | CIP096 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or after the ADMISSION-DATE. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP096-0004 |
| 373 | CIP096 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or before the ADJUDICATION-DATE. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP096-0005 |
| 374 | CIP096 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP096-0007 |
| 375 | CIP096 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible record | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP096-0008 |
| 376 | CIP097 | DISCHARGE-HOUR | The time of discharge from a hospital. | Conditional | Value must be a valid hour in military time format (00 to 23). | See Appendix A for listing of valid values. | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP097-0001 |
| 377 | CIP098 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0001 |
| 378 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0002 |
| 379 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0003 |
| 380 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0004 |
| 381 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | If a complete, valid date is not available or is unknown,leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0005 |
| 382 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0006 |
| 383 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or after the ADMISSION-DATE | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0007 |
| 384 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record when the eligible is not a CHIP unborn child. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0008 |
| 385 | CIP098 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP098-0009 |
| 386 | CIP099 | MEDICAID-PAID-DATE | The date Medicaid paid on this claim or adjustment. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP099-0001 |
| 387 | CIP099 | MEDICAID-PAID-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP099-0002 |
| 388 | CIP100 | TYPE-OF-CLAIM | A code indicating what kind of payment is covered in this claim. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP100-0001 |
| 389 | CIP100 | TYPE-OF-CLAIM | Not Applicable | NA | States should only submit CHIP claims for CHIP eligibles | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP100-0002 |
| 390 | CIP100 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the basis of eligibility. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP100-0003 |
| 391 | CIP100 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the maintenance assistance status. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP100-0004 |
| 392 | CIP100 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the restricted benefits code. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP100-0005 |
| 393 | CIP100 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the TANF code. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP100-0006 |
| 394 | CIP101 | TYPE-OF-BILL | A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.) | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP101-0001 |
| 395 | CIP102 | CLAIM-STATUS | The health care claim status codes convey the status of an entire claim. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP102-0001 |
| 396 | CIP102 | CLAIM-STATUS | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 397 | CIP103 | CLAIM-STATUS-CATEGORY | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.), which is then further detailed in the companion data element CLAIM-STATUS |
Required | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP103-0001 |
| 398 | CIP103 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All denied should must have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 399 | CIP103 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 400 | CIP104 | SOURCE-LOCATION | The field denotes the claims payment system from which the claim was extracted | Required | Value must be equal to a valid value. | 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) |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP104-0001 |
| 401 | CIP105 | CHECK-NUM | The check or EFT number. |
Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP105-0001 |
| 402 | CIP105 | CHECK-NUM | Not Applicable | NA | If there is a valid check date there should also be a valid check number. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP105-0002 |
| 403 | CIP106 | CHECK-EFF-DATE | Date the check is issued to the payee, or if Electronic Funds Transfer (EFT), the date the transfer is made. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP106-0001 |
| 404 | CIP106 | CHECK-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 405 | CIP106 | CHECK-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP106-0002 |
| 406 | CIP106 | CHECK-EFF-DATE | Not Applicable | NA | Could be the same as Remittance Date. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP106-0003 |
| 407 | CIP106 | CHECK-EFF-DATE | Not Applicable | NA | If there is a valid check number, there should also be a valid check date. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP106-0004 |
| 408 | CIP107 | ALLOWED-CHARGE-SRC | These codes indicate how each allowed charge was determined. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP107-0001 |
| 409 | CIP107 | ALLOWED-CHARGE-SRC | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare as the source to indicate how an allowed charge was determined on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP107-0002 |
| 410 | CIP108 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP108-0001 |
| 411 | CIP109 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP109-0001 |
| 412 | CIP110 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP110-0001 |
| 413 | CIP111 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP111-0001 |
| 414 | CIP112 | TOT-BILLED-AMT | The total amount billed for this claim at the claim header level as submitted by the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP112-0001 |
| 415 | CIP112 | TOT-BILLED-AMT | Not Applicable | NA | The total amount should be the sum of each of the billed amounts submitted at the claim detail level. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP112-0002 |
| 416 | CIP112 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000". | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP112-0003 |
| 417 | CIP112 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed the managed care plan. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP112-0004 |
| 418 | CIP113 | TOT-ALLOWED-AMT | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP113-0001 |
| 419 | CIP113 | TOT-ALLOWED-AMT | Not Applicable | NA | The sum of the allowed amounts at the detailed levels must equal TOT-ALLOWED-AMT | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP113-0002 |
| 420 | CIP114 | TOT-MEDICAID-PAID-AMT | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Required | If TYPE-OF-CLAIM = 1, A, U (fee-for-service claim) this field should be populated with the amount that the Medicaid agency paid to the provider. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP114-0001 |
| 421 | CIP114 | TOT-MEDICAID-PAID-AMT | Not Applicable | NA | If TYPE‐OF‐CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. |
Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP114-0002 |
| 422 | CIP115 | TOT-COPAY-AMT | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP115-0001 |
| 423 | CIP116 | TOT-MEDICARE-DEDUCTIBLE-AMT | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary’s Medicare deductible. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP116-0001 |
| 424 | CIP116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code MEDICARE-COMB-DED-IND with a "1", and code space in TOT-MEDICARE-COINS-AMT. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP116-0002 |
| 425 | CIP116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | The total Medicare deductible amount must be less than or equal the total billed amount. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP116-0003 |
| 426 | CIP117 | TOT-MEDICARE-COINS-AMT | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary’s Medicare coinsurance. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP117-0001 |
| 427 | CIP117 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | Value must be less than TOT-BILLED-AMT. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP117-0003 |
| 428 | CIP117 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | If the Medicare coinsurance amount can be identified separately from Medicare deductible amount, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, code space in this field, code MEDICARE-COMB-DED-IND with a "1", and fill the combined payment amount in TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP117-0005 |
| 429 | CIP118 | TOT-TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP118-0001 |
| 430 | CIP118 | TOT-TPL-AMT | Not Applicable | NA | The value of TOT-TPL-AMT should be less than (TOT-BILLED-AMT - (TOT-MEDICARE-COINS-AMT + TOT-MEDICARE-DEDUCTIBLE-AMT). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP118-0002 |
| 431 | CIP119 | TOT-OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP119-0001 |
| 432 | CIP121 | OTHER-INSURANCE-IND | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP121-0001 |
| 433 | CIP122 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP122-0001 |
| 434 | CIP123 | SERVICE-TRACKING-TYPE | A code to categorize service tracking claims. A “service tracking claim” is used to report lump sum payments that cannot be attributed to a single enrollee. (Note: Use an encounter record to report services provided under a capitated payment arrangement.) | Conditional | Value must be equal to a valid value. | 00 Not a Service Tracking Claim 01 Drug Rebate 02 DSH Payment 03 Lump Sum Payment 04 Cost Settlement 05 Supplemental 06 Other |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP123-0001 |
| 435 | CIP123 | SERVICE-TRACKING-TYPE | Not Applicable | NA | This field is required if TYPE-OF-CLAIM equals a service tracking claim (Valid values for service tracking claims include 4, D, X) | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 436 | CIP124 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Required on service tracking records, TYPE-OF-CLAIM equals 4, D, X) | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP124-0002 |
| 437 | CIP124 | SERVICE-TRACKING-PAYMENT-AMT | On service tracking claims, the lump sum amount paid to the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP124-0001 |
| 438 | CIP124 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Amount paid for services received by an individual patient, when the state accepts a lump sum form a provider that covered similar services delivered to more than one patient, such as a group screening for EPSDT. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP124-0003 |
| 439 | CIP124 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | For service tracking payments, ensure that the TOT-MEDICAID-PAID-AMOUNT is 0 filled and provide payment amount in SERVICE-TRACKING-PAYMENT-AMT only. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP124-0004 |
| 440 | CIP124 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | If there is a service tracking type, then there must also be a service tracking payment amount. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP124-0005 |
| 441 | CIP124 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | If SERVICE-TRACKING-TYPE <> "00" or "99", then SERVICE-TRACKING-PAYMENT-AMT must BE<> 000000000000. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP124-0006 |
| 442 | CIP125 | FIXED-PAYMENT-IND | This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management (PCCM) programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined “medical record” associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Conditional | Value must be equal to a valid value. | 0 Not Fixed Payment 1 FFS Fixed Payment |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP125-0001 |
| 443 | CIP126 | FUNDING-CODE | A code to indicate the source of non-federal share funds. | Required | Value must be equal to a valid value. | 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 |
10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP126-0001 |
| 444 | CIP127 | FUNDING-SOURCE-NONFEDERAL-SHARE | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. | Required | Value must be equal to a valid value. When states have multiple sources of FUNDING-SOURCE-NONFEDERAL-SHARE, States are to report the portion which represents the largest proportion as the 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP127-0001 |
| 445 | CIP128 | MEDICARE-COMB-DED-IND | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. |
Conditional | Value must be equal to a valid value. | 0 Amount not combined with coinsurance amount 1 Amount combined with coinsurance amount |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP128-0001 |
| 446 | CIP128 | MEDICARE-COMB-DED-IND | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any combined deductible amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP128-0003 |
| 447 | CIP129 | PROGRAM-TYPE | Code indicating special Medicaid program under which the service was provided. Refer to Appendix E for information on the various program types. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP129-0001 |
| 448 | CIP129 | PROGRAM-TYPE | Not Applicable | NA | Value for 1915 (c) waiver must correspond to the values for 1915(c) waiver in the Waiver Type. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP129-0002 |
| 449 | CIP129 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=Community First Choice (11) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 01 for the same time period. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP129-0003 |
| 450 | CIP129 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=1915(i) (value=13) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 02 for the same time period. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP129-0004 |
| 451 | CIP130 | PLAN-ID-NUMBER | A unique number, assigned by the state, which represents the health plan under which the non-fee-for-service encounter was provided including through the state plan and a waiver. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP130-0001 |
| 452 | CIP130 | PLAN-ID-NUMBER | Not Applicable | NA | Use the number as it is carried in the state’s system. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP130-0002 |
| 453 | CIP130 | PLAN-ID-NUMBER | Not Applicable | NA | The managed care ID on the individual's eligible record must match that which is included on any claims records (TYPE-OF-CLAIM= 3, C, W) for the eligible individual. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP130-0004 |
| 454 | CIP130 | PLAN-ID-NUMBER | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File" | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP130-0005 |
| 455 | CIP131 | NATIONAL-HEALTH-CARE-ENTITY-ID | The national identifier of the health care entity (controlling health plan, subhealth plan, or other entity) at the most granular sub-health plan level of the Medicaid or CHIP health plan in which an individual is enrolled. (See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP131-0001 |
| 456 | CIP131 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP131-0002 |
| 457 | CIP131 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | This field is required for all managed care claims and encounters with dates of service on or after the mandated dates above. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP131-0003 |
| 458 | CIP131 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | NATIONAL-HEALTH-CARE-ENTITY-IDs on managed care claims and encounters must match NATIONAL-HEALTH-CARE-ENTITY-IDs on file for the individual in the eligibility subject area or the TPL subject area | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP131-0004 |
| 459 | CIP132 | PAYMENT-LEVEL-IND | The field denotes whether the claim payment is made at the header level or the detail level. | Required | Value must be equal to a valid value. | 1 Claim Header – Sum of Line Item payments 2 Claim Detail – Individual Line Item payments |
4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP132-0001 |
| 460 | CIP132 | PAYMENT-LEVEL-IND | Not Applicable | NA | Payment fields at either the claim header or line on encounter records should be blank. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP132-0002 |
| 461 | CIP133 | MEDICARE-REIM-TYPE | This code indicates the type of Medicare Reimbursement. | Conditional | Value must be equal to a valid value. | 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 |
10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP133-0001 |
| 462 | CIP133 | MEDICARE-REIM-TYPE | Not Applicable | NA | If this is a crossover Medicare claim (CROSSOVER-IND= 1), the claim must have a MEDICARE-REIM-TYPE. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP133-0002 |
| 463 | CIP134 | NON-COV-DAYS | The number of days of inpatient care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered days does not refer to days not covered for any other service. | Conditional | Must contain number of non-covered days. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP134-0001 |
| 464 | CIP135 | NON-COV-CHARGES | The charges for inpatient care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP135-0001 |
| 465 | CIP136 | MEDICAID-COV-INPATIENT-DAYS | The number of inpatient days covered by Medicaid on this claim. For states that combine delivery/birth services on a single claim, include covered days for both the mother and the neonate in this field. |
Conditional | Must contain number of covered days. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP136-0001 |
| 466 | CIP136 | MEDICAID-COV-INPATIENT-DAYS | Not Applicable | NA | This field is applicable when a CLAIMIP record includes at least one accommodation REVENUE-CODE = (values 100-219). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP136-0002 |
| 467 | CIP136 | MEDICAID-COV-INPATIENT-DAYS | Not Applicable | NA | This total must not be greater than double the duration between the DISCHARGE-DATE and the ADMISSION-DATE, plus one day. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP136-0003 |
| 468 | CIP136 | MEDICAID-COV-INPATIENT-DAYS | Not Applicable | NA | This field is required if the Type of Service is 001, 058, 060, 84, 086, 090, 091, 092, 093, 123, 132. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP136-0004 |
| 469 | CIP137 | CLAIM-LINE-COUNT | The total number of lines on the claim | Required | Must be populated on every record | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP137-0001 |
| 470 | CIP137 | CLAIM-LINE-COUNT | Not Applicable | NA | If the number of claim lines is above the state-approved limit, the record will be split and the SPLIT-CLAIM-IND will equal 1. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP137-0002 |
| 471 | CIP137 | CLAIM-LINE-COUNT | Not Applicable | NA | The claim line count should equal the sum of the claim lines for this record. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP137-0003 |
| 472 | CIP138 | FORCED-CLAIM-IND | This code indicates if the claim was processed by forcing it through a manual override process. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP138-0001 |
| 473 | CIP139 | HEALTH-CARE-ACQUIRED-CONDITION-IND | This code indicates whether the claim has a Health Care Acquired Condition. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP139-0001 |
| 474 | CIP140 | OCCURRENCE-CODE-01 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP140-0001 |
| 475 | CIP140 | OCCURRENCE-CODE-01 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP140-0002 |
| 476 | CIP140 | OCCURRENCE-CODE-01 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP140-0003 |
| 477 | CIP141 | OCCURRENCE-CODE-02 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP141-0001 |
| 478 | CIP141 | OCCURRENCE-CODE-02 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP141-0002 |
| 479 | CIP141 | OCCURRENCE-CODE-02 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP141-0003 |
| 480 | CIP142 | OCCURRENCE-CODE-03 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP142-0001 |
| 481 | CIP142 | OCCURRENCE-CODE-03 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP142-0002 |
| 482 | CIP142 | OCCURRENCE-CODE-03 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP142-0003 |
| 483 | CIP143 | OCCURRENCE-CODE-04 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP143-0001 |
| 484 | CIP143 | OCCURRENCE-CODE-04 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP143-0002 |
| 485 | CIP143 | OCCURRENCE-CODE-04 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP143-0003 |
| 486 | CIP144 | OCCURRENCE-CODE-05 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP144-0001 |
| 487 | CIP144 | OCCURRENCE-CODE-05 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP144-0002 |
| 488 | CIP144 | OCCURRENCE-CODE-05 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP144-0003 |
| 489 | CIP145 | OCCURRENCE-CODE-06 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP145-0001 |
| 490 | CIP145 | OCCURRENCE-CODE-06 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP145-0002 |
| 491 | CIP145 | OCCURRENCE-CODE-06 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP145-0003 |
| 492 | CIP146 | OCCURRENCE-CODE-07 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP146-0001 |
| 493 | CIP146 | OCCURRENCE-CODE-07 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP146-0002 |
| 494 | CIP146 | OCCURRENCE-CODE-07 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP146-0003 |
| 495 | CIP147 | OCCURRENCE-CODE-08 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP147-0001 |
| 496 | CIP147 | OCCURRENCE-CODE-08 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP147-0002 |
| 497 | CIP147 | OCCURRENCE-CODE-08 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP147-0003 |
| 498 | CIP148 | OCCURRENCE-CODE-09 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP148-0001 |
| 499 | CIP148 | OCCURRENCE-CODE-09 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP148-0002 |
| 500 | CIP148 | OCCURRENCE-CODE-09 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP148-0003 |
| 501 | CIP149 | OCCURRENCE-CODE-10 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP149-0001 |
| 502 | CIP149 | OCCURRENCE-CODE-10 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP149-0002 |
| 503 | CIP149 | OCCURRENCE-CODE-10 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP149-0003 |
| 504 | CIP150 | OCCURRENCE-CODE-EFF-DATE-01 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP150-0001 |
| 505 | CIP150 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 506 | CIP150 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP150-0002 |
| 507 | CIP150 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP150-0003 |
| 508 | CIP150 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP150-0004 |
| 509 | CIP150 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP150-0005 |
| 510 | CIP150 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP150-0006 |
| 511 | CIP151 | OCCURRENCE-CODE-EFF-DATE-02 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP151-0001 |
| 512 | CIP151 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 513 | CIP151 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP151-0002 |
| 514 | CIP151 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP151-0003 |
| 515 | CIP151 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP151-0004 |
| 516 | CIP151 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP151-0005 |
| 517 | CIP151 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP151-0006 |
| 518 | CIP152 | OCCURRENCE-CODE-EFF-DATE-03 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP152-0001 |
| 519 | CIP152 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 520 | CIP152 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP152-0002 |
| 521 | CIP152 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP152-0003 |
| 522 | CIP152 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP152-0004 |
| 523 | CIP152 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP152-0005 |
| 524 | CIP152 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP152-0006 |
| 525 | CIP153 | OCCURRENCE-CODE-EFF-DATE-04 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP153-0001 |
| 526 | CIP153 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 527 | CIP153 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP153-0002 |
| 528 | CIP153 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP153-0003 |
| 529 | CIP153 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP153-0004 |
| 530 | CIP153 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP153-0005 |
| 531 | CIP153 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP153-0006 |
| 532 | CIP154 | OCCURRENCE-CODE-EFF-DATE-05 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP154-0001 |
| 533 | CIP154 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 534 | CIP154 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP154-0002 |
| 535 | CIP154 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP154-0003 |
| 536 | CIP154 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP154-0004 |
| 537 | CIP154 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP154-0005 |
| 538 | CIP154 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP154-0006 |
| 539 | CIP155 | OCCURRENCE-CODE-EFF-DATE-06 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP155-0001 |
| 540 | CIP155 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 541 | CIP155 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP155-0002 |
| 542 | CIP155 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP155-0003 |
| 543 | CIP155 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP155-0004 |
| 544 | CIP155 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP155-0005 |
| 545 | CIP155 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP155-0006 |
| 546 | CIP156 | OCCURRENCE-CODE-EFF-DATE-07 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP156-0001 |
| 547 | CIP156 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 548 | CIP156 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP156-0002 |
| 549 | CIP156 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP156-0003 |
| 550 | CIP156 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP156-0004 |
| 551 | CIP156 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP156-0005 |
| 552 | CIP156 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP156-0006 |
| 553 | CIP157 | OCCURRENCE-CODE-EFF-DATE-08 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP157-0001 |
| 554 | CIP157 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 555 | CIP157 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP157-0002 |
| 556 | CIP157 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP157-0003 |
| 557 | CIP157 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP157-0004 |
| 558 | CIP157 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP157-0005 |
| 559 | CIP157 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP157-0006 |
| 560 | CIP158 | OCCURRENCE-CODE-EFF-DATE-09 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP158-0001 |
| 561 | CIP158 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 562 | CIP158 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP158-0002 |
| 563 | CIP158 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP158-0003 |
| 564 | CIP158 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP158-0004 |
| 565 | CIP158 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP158-0005 |
| 566 | CIP158 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP158-0006 |
| 567 | CIP159 | OCCURRENCE-CODE-EFF-DATE-10 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP159-0001 |
| 568 | CIP159 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 569 | CIP159 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP159-0002 |
| 570 | CIP159 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP159-0003 |
| 571 | CIP159 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP159-0004 |
| 572 | CIP159 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP159-0005 |
| 573 | CIP159 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP159-0006 |
| 574 | CIP160 | OCCURRENCE-CODE-END-DATE-01 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP160-0001 |
| 575 | CIP160 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP160-0002 |
| 576 | CIP160 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP160-0003 |
| 577 | CIP160 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP160-0004 |
| 578 | CIP160 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP160-0005 |
| 579 | CIP160 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP160-0006 |
| 580 | CIP161 | OCCURRENCE-CODE-END-DATE-02 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP161-0001 |
| 581 | CIP161 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP161-0002 |
| 582 | CIP161 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP161-0003 |
| 583 | CIP161 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP161-0004 |
| 584 | CIP161 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP161-0005 |
| 585 | CIP161 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP161-0006 |
| 586 | CIP162 | OCCURRENCE-CODE-END-DATE-03 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP162-0001 |
| 587 | CIP162 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP162-0002 |
| 588 | CIP162 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP162-0003 |
| 589 | CIP162 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP162-0004 |
| 590 | CIP162 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP162-0005 |
| 591 | CIP162 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP162-0006 |
| 592 | CIP163 | OCCURRENCE-CODE-END-DATE-04 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP163-0001 |
| 593 | CIP163 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP163-0002 |
| 594 | CIP163 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP163-0003 |
| 595 | CIP163 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP163-0004 |
| 596 | CIP163 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP163-0005 |
| 597 | CIP163 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP163-0006 |
| 598 | CIP164 | OCCURRENCE-CODE-END-DATE-05 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP164-0001 |
| 599 | CIP164 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP164-0002 |
| 600 | CIP164 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP164-0003 |
| 601 | CIP164 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP164-0004 |
| 602 | CIP164 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP164-0005 |
| 603 | CIP164 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP164-0006 |
| 604 | CIP165 | OCCURRENCE-CODE-END-DATE-06 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP165-0001 |
| 605 | CIP165 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP165-0002 |
| 606 | CIP165 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP165-0003 |
| 607 | CIP165 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP165-0004 |
| 608 | CIP165 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP165-0005 |
| 609 | CIP165 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP165-0006 |
| 610 | CIP166 | OCCURRENCE-CODE-END-DATE-07 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP166-0001 |
| 611 | CIP166 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP166-0002 |
| 612 | CIP166 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP166-0003 |
| 613 | CIP166 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP166-0004 |
| 614 | CIP166 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP166-0005 |
| 615 | CIP166 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP166-0006 |
| 616 | CIP167 | OCCURRENCE-CODE-END-DATE-08 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP167-0001 |
| 617 | CIP167 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP167-0002 |
| 618 | CIP167 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP167-0003 |
| 619 | CIP167 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP167-0004 |
| 620 | CIP167 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP167-0005 |
| 621 | CIP167 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP167-0006 |
| 622 | CIP168 | OCCURRENCE-CODE-END-DATE-09 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP168-0001 |
| 623 | CIP168 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP168-0002 |
| 624 | CIP168 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP168-0003 |
| 625 | CIP168 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP168-0004 |
| 626 | CIP168 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP168-0005 |
| 627 | CIP168 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP168-0006 |
| 628 | CIP169 | OCCURRENCE-CODE-END-DATE-10 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP169-0001 |
| 629 | CIP169 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP169-0002 |
| 630 | CIP169 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP169-0003 |
| 631 | CIP169 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP169-0004 |
| 632 | CIP169 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP169-0005 |
| 633 | CIP169 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP169-0006 |
| 634 | CIP170 | BIRTH-WEIGHT-GRAMS | The weight of a newborn at time of birth in grams (applicable to newborns only). | Conditional | Required for a claim involving child birth | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP170-0001 |
| 635 | CIP171 | PATIENT-CONTROL-NUM | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client’s episode of service within the provider’s system to facilitate retrieval of individual financial and clinical records and posting of payment | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP171-0001 |
| 636 | CIP172 | ELIGIBLE-LAST-NAME | The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP172-0001 |
| 637 | CIP172 | ELIGIBLE-LAST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP172-0002 |
| 638 | CIP173 | ELIGIBLE-FIRST-NAME | The first name of the individual to whom the services were provided.(The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP173-0001 |
| 639 | CIP173 | ELIGIBLE-FIRST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP173-0002 |
| 640 | CIP174 | ELIGIBLE-MIDDLE-INIT | The middle initial of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP174-0001 |
| 641 | CIP174 | ELIGIBLE-MIDDLE-INIT | Not Applicable | NA | Leave blank if not available. When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. |
Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP174-0002 |
| 642 | CIP175 | DATE-OF-BIRTH | Date of birth of the individual to whom the services were provided. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP175-0001 |
| 643 | CIP175 | DATE-OF-BIRTH | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP175-0002 |
| 644 | CIP175 | DATE-OF-BIRTH | Not Applicable | NA | The numeric form for days and months from 1 to 9 must have a zero as the first digit. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP175-0003 |
| 645 | CIP175 | DATE-OF-BIRTH | Not Applicable | NA | A patient's age should not be greater than 112 years. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP175-0005 |
| 646 | CIP176 | HEALTH-HOME-PROV-IND | This code indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP176-0001 |
| 647 | CIP176 | HEALTH-HOME-PROV-IND | Not Applicable | NA | If a state has not yet begun collecting this information, HEALTH-HOME-PROV-IND, this field should be defaulted to the value “8.” | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP176-0002 |
| 648 | CIP176 | HEALTH-HOME-PROV-IND | Not Applicable | NA | If there is a HEALTH-HOME-ENTITY-NAME then HEALTH-HOME-PROV-IND must indicate yes. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP176-0003 |
| 649 | CIP176 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States should not submit claim records for an eligible individual that indicate the claim was submitted by a provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP176-0004 |
| 650 | CIP176 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP176-0005 |
| 651 | CIP177 | WAIVER-TYPE | Code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Conditional | Enter the WAIVER-TYPE assigned | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP177-0001 |
| 652 | CIP177 | WAIVER-TYPE | Not Applicable | NA | Value must correspond to associated WAIVER-ID | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP177-0002 |
| 653 | CIP177 | WAIVER-TYPE | Not Applicable | NA | An ineligible individual should not have a category for federal reimbursement for Medicaid or CHIP (CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT <> 01,02) | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP177-0003 |
| 654 | CIP178 | WAIVER-ID | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. The categories of demonstration and waiver programs include: 1915(b)(1); 1915(b)(2); 1915(b)(3), and 1915(b)(4) managed care waivers; 1915(c) home and community based services waivers; combined 1915(b) and 1915(c) managed home and community based services waivers and 1115 demonstrations. | Conditional | Not Applicable | Valid values are supplied by the state. | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 655 | CIP178 | WAIVER-ID | Not Applicable | NA | Report the full federal waiver identifier. | Not Applicable | 11/9/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP178-0002 |
| 656 | CIP178 | WAIVER-ID | Not Applicable | NA | If the goods & services rendered do not fall under a waiver, leave this field blank. | Not Applicable | 11/9/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP178-0004 |
| 657 | CIP178 | WAIVER-ID | Not Applicable | NA | If there's a waiver type, there should be a corresponding waiver id. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP178-0005 |
| 658 | CIP179 | BILLING-PROV-NUM | A unique identification number assigned by the state to a provider or capitation plan. This should represent the entity billing for the service. | Required | If value is invalid, record it exactly as it appears in the state system. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP179-0001 |
| 659 | CIP179 | BILLING-PROV-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), this represents the entity billing (or reporting) to the managed care plan (See PLAN-ID-NUMBER for reporting capitation plan-ID). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP179-0002 |
| 660 | CIP179 | BILLING-PROV-NUM | Not Applicable | NA | Billing Provider must not be an individual or group on inpatient hospital claims. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP179-0003 |
| 661 | CIP179 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP179-0004 |
| 662 | CIP179 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP179-0005 |
| 663 | CIP179 | BILLING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP179-0006 |
| 664 | CIP180 | BILLING-PROV-NPI-NUM | The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. |
Required | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP180-0001 |
| 665 | CIP180 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP180-0002 |
| 666 | CIP180 | BILLING-PROV-NPI-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity billing (or reporting) to the managed care plan. For financial transactions (i.e., expenditure transactions or recoupments of previously made expenditures that do not flow through the usual claim adjudication/adjustment process or encounter record reporting process), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity to which the financial transaction was addressed, unless the transaction is a payment/recoupment made-to/received-from a managed care plan, in which case the BILLING-PROV-NPI-NUM should be left blank. For financial transactions with managed care plans, the plan's ID should be reported in the PLAN-ID-NUMBER field and the BILLING-PROV-NPI-NUM should be left blank. |
Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP180-0003 |
| 667 | CIP180 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Billing Provider must be enrolled | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP180-0005 |
| 668 | CIP180 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Billing Provider must not be an individual or group on inpatient hospital claims. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP180-0006 |
| 669 | CIP181 | BILLING-PROV-TAXONOMY | For CLAIMIP and CLAIMLT files, the taxonomy code for the institution billing for the beneficiary. |
Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP181-0001 |
| 670 | CIP181 | BILLING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP181-0002 |
| 671 | CIP182 | BILLING-PROV-TYPE | A code describing the type of entity billing for the service. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP182-0001 |
| 672 | CIP182 | BILLING-PROV-TYPE | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM= 3, C, W), this represents the entity billing (or reporting) to the Managed Care Plan (see PLAN-ID-NUMBER for reporting capitation plan-ID). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP182-0002 |
| 673 | CIP182 | BILLING-PROV-TYPE | Not Applicable | NA | The state should use Taxonomy Crosswalk.pdf to crosswalk state codes to CMS codes | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP182-0003 |
| 674 | CIP183 | BILLING-PROV-SPECIALTY | This code describes the area of specialty for the billing provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP183-0001 |
| 675 | CIP184 | ADMITTING-PROV-NPI-NUM | The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | Conditional | Valid characters include only numbers (0-9) | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP184-0001 |
| 676 | CIP184 | ADMITTING-PROV-NPI-NUM | Not Applicable | NA | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP184-0002 |
| 677 | CIP185 | ADMITTING-PROV-NUM | The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | Required | If value is invalid, record it exactly as it appears in the state system | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP185-0001 |
| 678 | CIP185 | ADMITTING-PROV-NUM | Not Applicable | NA | Note: Once a national provider ID numbering system is in place, the national number should be used. If the State’s legacy ID number is also available then that number can be entered in this field. |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP185-0002 |
| 679 | CIP185 | ADMITTING-PROV-NUM | Not Applicable | NA | The value reported in ADMITTING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP185-0003 |
| 680 | CIP185 | ADMITTING-PROV-NUM | Not Applicable | NA | The value reported in ADMITTING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP185-0004 |
| 681 | CIP185 | ADMITTING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP185-0005 |
| 682 | CIP186 | ADMITTING-PROV-SPECIALTY | This code describes the area of specialty for the admitting provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP186-0001 |
| 683 | CIP187 | ADMITTING-PROV-TAXONOMY | The taxonomy code for the admitting provider. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP187-0001 |
| 684 | CIP187 | ADMITTING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP187-0002 |
| 685 | CIP188 | ADMITTING-PROV-TYPE | A code describing the type of admitting provider. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided. |
Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP188-0001 |
| 686 | CIP189 | REFERRING-PROV-NUM | A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual’s ID number, not a group identification number. | Conditional | If Value is invalid, record it exactly as it appears in the State system. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP189-0001 |
| 687 | CIP189 | REFERRING-PROV-NUM | Not Applicable | NA | If the referring provider number is not available, but the physician’s Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP189-0002 |
| 688 | CIP189 | REFERRING-PROV-NUM | Not Applicable | NA | The value reported in REFERRING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP189-0003 |
| 689 | CIP189 | REFERRING-PROV-NUM | Not Applicable | NA | The value reported in REFERRING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP189-0004 |
| 690 | CIP189 | REFERRING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP189-0005 |
| 691 | CIP190 | REFERRING-PROV-NPI-NUM | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | Conditional | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP190-0001 |
| 692 | CIP190 | REFERRING-PROV-NPI-NUM | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP190-0002 |
| 693 | CIP191 | REFERRING-PROV-TAXONOMY | For CLAIMIP and CLAIMLT files, the taxonomy code for the referring provider. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP191-0001 |
| 694 | CIP191 | REFERRING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP191-0002 |
| 695 | CIP192 | REFERRING-PROV-TYPE | A code describing the type of provider (i.e. doctor) who referred the patient. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided. |
NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP192-0001 |
| 696 | CIP193 | REFERRING-PROV-SPECIALTY | This code indicates the area of specialty of the referring provider. | NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP193-0001 |
| 697 | CIP194 | DRG-OUTLIER-AMT | The additional payment on a claim that is associated with either a cost outlier or length of stay outlier. Outlier payments compensate hospitals paid on a fixed amount per Medicare "diagnosis related group" discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category. |
Conditional | This data element must include a valid dollar amount. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP194-0001 |
| 698 | CIP194 | DRG-OUTLIER-AMT | Not Applicable | NA | If there is an outlier-code then there must be an outlier amount. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP194-0002 |
| 699 | CIP195 | DRG-REL-WEIGHT | The relative weight for the DRG on the claim. Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average. | Conditional | State specific | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP195-0001 |
| 700 | CIP196 | MEDICARE-HIC-NUM | Health Insurance Claim (HIC) Number as it appears on the patient’s Medicare card. |
Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP196-0001 |
| 701 | CIP196 | MEDICARE-HIC-NUM | Not Applicable | NA | If this is a crossover Medicare claim, the Bene must have a MEDICARE-HIC-Num. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP196-0003 |
| 702 | CIP196 | MEDICARE-HIC-NUM | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's Medicare HIC Number does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP196-0004 |
| 703 | CIP196 | MEDICARE-HIC-NUM | Not Applicable | NA | Claims records for an eligible individual should not indicate a valid Medicare HIC number, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP196-0005 |
| 704 | CIP197 | OUTLIER-CODE | This code indicates the Type of Outlier Code or DRG Source. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP197-0001 |
| 705 | CIP197 | OUTLIER-CODE | Not Applicable | NA | If there is an outlier-amount, then there is an outlier-code. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP197-0002 |
| 706 | CIP198 | OUTLIER-DAYS | This field specifies the number of days paid as outliers under Prospective Payment System (PPS) and the days over the threshold for the DRG | Conditional | Must be numeric | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP198-0001 |
| 707 | CIP198 | OUTLIER-DAYS | Not Applicable | NA | Used in conjunction with OUTLIER-CODE field. The field identifies two mutually exclusive conditions. The first, for PPS providers (codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-PPS providers (codes 6, 7, 8, and 9), denotes the source for developing the DRG. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP198-0002 |
| 708 | CIP198 | OUTLIER-DAYS | Not Applicable | NA | If the unit of the outlier is days, then the outlier-days should not be missing. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP198-0003 |
| 709 | CIP199 | PATIENT-STATUS | A code indicating the Patients status as of the ENDING-DATE-OF-SERVICE. Values used are from UB-04. This is also referred to as DISCHARGE-STATUS. | Required | Value must be equal to a valid value. | To order the current edition of the UB-04 Data Specifications Manual go to: http://www.nubc.org/subscriber/index.dhtml To order the current edition of the UB-04 Data Specifications Manual go to: http://www.nubc.org/subscriber/index.dhtml | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP199-0001 |
| 710 | CIP199 | PATIENT-STATUS | Not Applicable | NA | If the date of death is valued, then the patient status should indicate that the patient has expired. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP199-0002 |
| 711 | CIP199 | PATIENT-STATUS | Not Applicable | NA | Obtain the Patient Discharge Status valid value set which is published in the UB-04 Data Specifications Manual. 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 |
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 | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP199-0003 |
| 712 | CIP201 | BMI | A key index for relating a person's body weight to their height. The body mass index (BMI) is a person's weight in kilograms (kg) divided by their height in meters (m) squared. | Optional | SI units: BMI = mass (kg) / (height(m))2 Imperial/US Customary units: BMI = mass (lb) * 703/ (height(in))2 BMI = mass (lb) * 4.88/ (height(ft))2 BMI = mass (st) * 9840/ (height(in))2 |
Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP201-0001 |
| 713 | CIP201 | BMI | Not Applicable | NA | CMS is relieving states of the responsibility to: (a) Provide these data. (b) Document a mitigation plan in the Source-to-Target-Mapping Matrix Addendum B whenever the data elements cannot be populated all of the time. However if a state determines that it can populate one or more of these fields and wishes to do so, they are encouraged to do so and will not incur any Addendum B mitigation plan documentation expectations. |
Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP201-0002 |
| 714 | CIP202 | REMITTANCE-NUM | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP202-0001 |
| 715 | CIP202 | REMITTANCE-NUM | Not Applicable | NA | Value must not be null | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP202-0002 |
| 716 | CIP202 | REMITTANCE-NUM | Not Applicable | NA | If there is a remittance date, then there must also be a remittance number. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP202-0003 |
| 717 | CIP203 | SPLIT-CLAIM-IND | An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP203-0001 |
| 718 | CIP203 | SPLIT-CLAIM-IND | Not Applicable | NA | If the claim has been split, the Transaction Handling Code indicator will indicate a Split Payment and Remittance (1000 BPR01 = U). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP203-0002 |
| 719 | CIP204 | BORDER-STATE-IND | This code indicates whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP204-0001 |
| 720 | CIP206 | BENEFICIARY-COINSURANCE-AMOUNT | The amount of money the beneficiary paid towards coinsurance. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP206-0001 |
| 721 | CIP206 | BENEFICIARY-COINSURANCE-AMOUNT | Not Applicable | NA | If no coinsurance is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP206-0002 |
| 722 | CIP206 | BENEFICIARY-COINSURANCE-AMOUNT | Not Applicable | NA | If it is unknown whether coinsurance was paid, 9 fill, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP206-0003 |
| 723 | CIP207 | BENEFICIARY-COINSURANCE-DATE-PAID | The date the beneficiary paid the coinsurance amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP207-0001 |
| 724 | CIP207 | BENEFICIARY-COINSURANCE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP207-0002 |
| 725 | CIP207 | BENEFICIARY-COINSURANCE-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP207-0003 |
| 726 | CIP208 | BENEFICIARY-COPAYMENT-AMOUNT | The amount of money the beneficiary paid towards a copayment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP208-0001 |
| 727 | CIP208 | BENEFICIARY-COPAYMENT-AMOUNT | Not Applicable | NA | If no copayment is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP208-0002 |
| 728 | CIP209 | BENEFICIARY-COPAYMENT-DATE-PAID | The date the beneficiary paid the copayment amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP209-0001 |
| 729 | CIP209 | BENEFICIARY-COPAYMENT-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP209-0002 |
| 730 | CIP209 | BENEFICIARY-COPAYMENT-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable,leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP209-0003 |
| 731 | CIP210 | BENEFICIARY-DEDUCTIBLE-AMOUNT | The amount of money the beneficiary paid towards an annual deductible. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP210-0001 |
| 732 | CIP210 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Not Applicable | NA | If no deductible is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP210-0002 |
| 733 | CIP210 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Not Applicable | NA | If it is unknown whether a deductible was paid, 9 fill, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP210-0003 |
| 734 | CIP211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | The date the beneficiary paid the deductible amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP211-0001 |
| 735 | CIP211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP211-0002 |
| 736 | CIP211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP211-0003 |
| 737 | CIP212 | CLAIM-DENIED-INDICATOR | An indicator to identify a claim that the state refused pay in its entirety. | Conditional | Value must be equal to a valid value. | 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. |
11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP212-0001 |
| 738 | CIP212 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | It is expected that states will submit all denied claims to CMS. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP212-0002 |
| 739 | CIP212 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All denied claims should have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP212-0003 |
| 740 | CIP212 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 741 | CIP213 | COPAY-WAIVED-IND | An indicator signifying that the copay was waived by the provider. | Optional | Value must be equal to a valid value. | 0 Not Waived: The provider did not waive the beneficiary’s copayment 1 Waived: The provider waived the beneficiary’s copayment |
8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP213-0001 |
| 742 | CIP214 | HEALTH-HOME-ENTITY-NAME | A free-form text field to indicate the health home program that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A “Health Home Entity” can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities’ names are being used instead. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP214-0001 |
| 743 | CIP214 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's health home entity name does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP214-0002 |
| 744 | CIP216 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item | Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP216-0001 |
| 745 | CIP217 | THIRD-PARTY-COINSURANCE-DATE-PAID | The date the third party paid the coinsurance amount | Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP217-0001 |
| 746 | CIP217 | THIRD-PARTY-COINSURANCE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP217-0002 |
| 747 | CIP218 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | The amount the third party paid the copayment amount. | Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP218-0001 |
| 748 | CIP218 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Not Applicable | NA | If the field is not applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP218-0002 |
| 749 | CIP219 | THIRD-PARTY-COPAYMENT-DATE-PAID | The date the third party paid the copayment amount. | Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP219-0001 |
| 750 | CIP219 | THIRD-PARTY-COPAYMENT-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP219-0002 |
| 751 | CIP220 | MEDICAID-AMOUNT-PAID-DSH | The amount included in the TOT-MEDICAID-PAID-AMT that is attributable to a Disproportionate Share Hospital (DSH) payment, when the state makes DSH payments by claim. |
Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP220-0001 |
| 752 | CIP221 | HEALTH-HOME-PROVIDER-NPI | The National Provider ID (NPI) of the health home provider. | Conditional | The value must be a valid NPI | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP221-0001 |
| 753 | CIP221 | HEALTH-HOME-PROVIDER-NPI | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP221-0002 |
| 754 | CIP222 | MEDICARE-BENEFICIARY-IDENTIFIER | The individual’s Medicare Beneficiary Identifier (MBI) Identification Number. Note: MBI replaces the HICN with an entirely new Medicare Beneficiary Identifier (MBI) for purposes of provider billing, if applicable. CMS interfaces with non-payment exchange partners would remain HICN-based, while interfaces with payment partners would use the new MBI. |
NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP222-0001 |
| 755 | CIP222 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | If individual is NOT enrolled in Medicare, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP222-0002 |
| 756 | CIP222 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) until such time as the Medicare Beneficiary Identifier is implemented (no target date has been established). | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP222-0003 |
| 757 | CIP223 | OPERATING-PROV-TAXONOMY | The Provider Taxonomy of the provider who performed an operation on the patient. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP223-0001 |
| 758 | CIP223 | OPERATING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP223-0002 |
| 759 | CIP223 | OPERATING-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP223-0003 |
| 760 | CIP224 | UNDER-DIRECTION-OF-PROV-NPI | The National Provider ID (NPI) of the provider who directed the care of a patient that another provider administered. | NA | Not Applicable | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 761 | CIP224 | UNDER-DIRECTION-OF-PROV-NPI | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP224-0002 |
| 762 | CIP224 | UNDER-DIRECTION-OF-PROV-NPI | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). This data element is a duplicate of the “UNDER-SUPERVISION-OF-PROV-NPI” field and as such do not need to be populated. | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP224-0003 |
| 763 | CIP225 | UNDER-DIRECTION-OF-PROV-TAXONOMY | The Provider Taxonomy of the provider who directed the care of a patient that another provider administered. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP225-0001 |
| 764 | CIP225 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP225-0002 |
| 765 | CIP225 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP225-0003 |
| 766 | CIP225 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). This data element is a duplicate of the “UNDER-SUPERVISION-OF-PROV-TAXONOMY” field and as such do not need to be populated. | Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP225-0004 |
| 767 | CIP226 | UNDER-SUPERVISION-OF-PROV-NPI | The National Provider ID (NPI) of the provider who supervised another provider. | NA | Not Applicable | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable |
| 768 | CIP226 | UNDER-SUPERVISION-OF-PROV-NPI | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP226-0002 |
| 769 | CIP227 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | The Provider Taxonomy of the provider who supervised another provider. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP227-0001 |
| 770 | CIP227 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP227-0002 |
| 771 | CIP227 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP227-0003 |
| 772 | CIP228 | MEDICARE-PAID-AMT | The amount paid by Medicare on this claim or adjustment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP228-0001 |
| 773 | CIP228 | MEDICARE-PAID-AMT | Not Applicable | NA | If the service was covered by Medicare but Medicare had no liability for the bill, zero-fill. MEDICARE-PAID-AMT should reflect the actual amount paid by Medicare. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP228-0002 |
| 774 | CIP228 | MEDICARE-PAID-AMT | Not Applicable | NA | For claims where Medicare payment is only available at the header level, report the entire payment amount the T-MSIS record corresponding to the line item with the highest charge. Zero fill Medicare Amount Paid on all other T-MSIS records created from the original claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP228-0003 |
| 775 | CIP228 | MEDICARE-PAID-AMT | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP228-0004 |
| 776 | CIP229 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP229-0001 |
| 777 | CIP229 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP229-0002 |
| 778 | CIP230 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP230-0001 |
| 779 | CIP231 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002 | Required | Value must be equal to a valid value. | CIP00003 | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP231-0001 |
| 780 | CIP231 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP231-0002 |
| 781 | CIP232 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP232-0001 |
| 782 | CIP232 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP232-0002 |
| 783 | CIP232 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP232-0003 |
| 784 | CIP232 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP232-0004 |
| 785 | CIP233 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP233-0001 |
| 786 | CIP233 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP233-0002 |
| 787 | CIP233 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP233-0003 |
| 788 | CIP234 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP234-0001 |
| 789 | CIP234 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the state ID numbers must be supplied to CMS | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP234-0002 |
| 790 | CIP234 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For TYPE-OF-CLAIM = 4 or D (lump sum adjustments), this field must begin with an ‘&’. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP234-0003 |
| 791 | CIP234 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP234-0004 |
| 792 | CIP235 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP235-0001 |
| 793 | CIP235 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP235-0002 |
| 794 | CIP235 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP235-0003 |
| 795 | CIP235 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable |
| 796 | CIP236 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP236-0001 |
| 797 | CIP236 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP236-0002 |
| 798 | CIP236 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP236-0003 |
| 799 | CIP237 | LINE-NUM-ORIG | A unique number to identify the transaction line number that is being reported on the original claim. | Required | Record the value exactly as it appears in the State system. Do not pad. This field should also be completed on adjustment claims to reflect the LINE-NUMBER of the INTERNAL-CONTROL-NUMBER on the claim that is being adjusted. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP237-0001 |
| 800 | CIP238 | LINE-NUM-ADJ | A unique number to identify the transaction line number that identifies the line number on the adjustment ICN. | Conditional | Record the value exactly as it appears in the state system. Do not pad. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP238-0001 |
| 801 | CIP238 | LINE-NUM-ADJ | Not Applicable | NA | This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number. |
Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable |
| 802 | CIP239 | LINE-ADJUSTMENT-IND | Code indicating type of adjustment record claim/encounter represents at claim detail level. | Conditional | Value must be equal to a valid value. | 0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP239-0001 |
| 803 | CIP239 | LINE-ADJUSTMENT-IND | Not Applicable | NA | If there is a line adjustment number, then there must be a line-adjustment indicator. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP239-0002 |
| 804 | CIP239 | LINE-ADJUSTMENT-IND | Not Applicable | NA | Value must be equal to a valid value. ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "3", "5", "A", "C", "E", "U", "W", "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP239-0004 |
| 805 | CIP240 | LINE-ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP240-0001 |
| 806 | CIP240 | LINE-ADJUSTMENT-REASON-CODE | Not Applicable | NA | If there is no adjustment to a line, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE) | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP240-0002 |
| 807 | CIP241 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to the state’s claim adjudication system. |
Conditional | Value must not be null | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP241-0001 |
| 808 | CIP242 | CLAIM-LINE-STATUS | The claim line status codes identify the status of a specific detail claim line rather than the entire claim. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP242-0001 |
| 809 | CIP243 | BEGINNING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0001 |
| 810 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0002 |
| 811 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before or be the same as the end of time period | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0003 |
| 812 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as Ending Date of Service | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0004 |
| 813 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as adjudication date. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0005 |
| 814 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0006 |
| 815 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before the DATE-OF-BIRTH when the person is eligible as an unborn CHIP child or beginning date of service must occur on or after the DATE-OF-BIRTH when the person is eligible through Medicaid or is eligible as a non-unborn CHIP child . | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0007 |
| 816 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A Medicaid claim record for an eligible individual should not have a Beginning Date of Service after the eligible individual's Medicaid enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0008 |
| 817 | CIP243 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A CHIP claim record for an individual eligible for Separate CHIP cannot have a Beginning Date of Service after the eligible individual's CHIP enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP243-0009 |
| 818 | CIP244 | ENDING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP244-0001 |
| 819 | CIP244 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP244-0002 |
| 820 | CIP244 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must occur after or be the same as the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP244-0003 |
| 821 | CIP244 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP244-0004 |
| 822 | CIP244 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before the Date of Death. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP244-0005 |
| 823 | CIP244 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or after DATE-OF-BIRTH | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP244-0006 |
| 824 | CIP244 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as End of Time Period. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP244-0007 |
| 825 | CIP245 | REVENUE-CODE | A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing Manual). | Required | Only valid codes as defined by the “National Uniform Billing Committee” should be used. | Revenue code is a data set that health care providers or insurers usually pay for to use. These values will change annually. | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP245-0001 |
| 826 | CIP245 | REVENUE-CODE | Not Applicable | NA | Enter all UB-04 Revenue Codes listed on the claim | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP245-0002 |
| 827 | CIP245 | REVENUE-CODE | Not Applicable | NA | Value must be a valid code | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP245-0003 |
| 828 | CIP245 | REVENUE-CODE | Not Applicable | NA | If value invalid, record it exactly as it appears in the state system | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP245-0004 |
| 829 | CIP248 | IMMUNIZATION-TYPE | This field identifies the type of immunization provided in order to track additional detail not currently contained in CPT codes. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP248-0001 |
| 830 | CIP249 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. | Required | Must be numeric | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP249-0001 |
| 831 | CIP249 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP249-0002 |
| 832 | CIP249 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | Not Applicable | NA | For use with CLAIMIP and CLAIMLT claims. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP249-0003 |
| 833 | CIP250 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. | Conditional | Must be numeric | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP250-0001 |
| 834 | CIP250 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP250-0002 |
| 835 | CIP250 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | Not Applicable | NA | For use with CLAIMIP and CLAIMLT claims. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP250-0003 |
| 836 | CIP251 | REVENUE-CHARGE | The total charge for the related UB-04 Revenue Code (REVENUE-CODE). Total charges include both covered and non-covered charges (as defined by UB-04 Billing Manual) | Required | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP251-0001 |
| 837 | CIP251 | REVENUE-CHARGE | Not Applicable | NA | Enter charge for each UB-04 Revenue Code listed on the claim | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP251-0002 |
| 838 | CIP251 | REVENUE-CHARGE | Not Applicable | NA | The total amount should be the sum of each of the charged amounts submitted at the claim detail level | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP251-0003 |
| 839 | CIP251 | REVENUE-CHARGE | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should either be zero-filled or contain the amount paid by the plan to the provider. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP251-0004 |
| 840 | CIP251 | REVENUE-CHARGE | Not Applicable | NA | The sum of claim line charges (REVENUE-CHARGE) should be less than or equal to the TOT-BILLED-AMT | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP251-0005 |
| 841 | CIP251 | REVENUE-CHARGE | Not Applicable | NA | Value must be left blank or space-filled if the revenue code is blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP251-0006 |
| 842 | CIP251 | REVENUE-CHARGE | Not Applicable | NA | Value must not be left blank or space-filled if the revenue code is not blank or space-filled | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP251-0007 |
| 843 | CIP252 | ALLOWED-AMT | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP252-0001 |
| 844 | CIP253 | TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP253-0001 |
| 845 | CIP254 | MEDICAID-PAID-AMT | The total amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim detail level. | Required | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP254-0001 |
| 846 | CIP254 | MEDICAID-PAID-AMT | Not Applicable | NA | For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP254-0002 |
| 847 | CIP254 | MEDICAID-PAID-AMT | Not Applicable | NA | For Crossover claims with Medicare Coinsurance and/or Deductibles, enter the sum of those amounts in the Medicaid-Amount-Paid field, if the providers were reimbursed by Medicaid for them. If the Coinsurance and Deductibles were not paid by the state, then report the Medicaid-Amount-Paid as $0 | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP254-0003 |
| 848 | CIP255 | MEDICAID-FFS-EQUIVALENT-AMT | The MEDICAID-FFS-EQUIVALENT-AMT field should be populated with the amount that would have been paid had the services been provided on a FFS basis. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP255-0001 |
| 849 | CIP255 | MEDICAID-FFS-EQUIVALENT-AMT | Not Applicable | NA | Required when TYPE-OF-CLAIM = 3, C, or W | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP255-0002 |
| 850 | CIP256 | BILLING-UNIT | Unit of billing that is used for billing services by the facility. | Conditional | Value must be equal to a valid value. | 01 Per Day 02 Per Hour 03 Per Case 04 Per Encounter 05 Per Week 06 Per Month 07 Other Arrangements |
8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP256-0001 |
| 851 | CIP257 | TYPE-OF-SERVICE | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP257-0001 |
| 852 | CIP257 | TYPE-OF-SERVICE | Not Applicable | NA | All claims for inpatient psychiatric care provided in a separately administered psychiatric wing or psychiatric hospital are included in the CLAIMLT file. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP257-0002 |
| 853 | CIP257 | TYPE-OF-SERVICE | Not Applicable | NA | Experience has demonstrated there can be instances when more than one service area category could be applicable for a provided service. The following hierarchy rules apply to these instances: o The specific service categories of sterilizations and other pregnancy-related procedures take precedence over provider categories, such as inpatient hospital or outpatient hospital. o Services of a physician employed by a clinic are reported under clinic services if the clinic is the billing entity. X-rays processed by the clinic in the course of treatment, however, are reported under X-ray services. o Services of a registered nurse attending a resident in a NF are reported (if they qualified under the coverage rules) under home health services if they were not billed as part of the NF bill. |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP257-0003 |
| 854 | CIP257 | TYPE-OF-SERVICE | Not Applicable | NA | See Appendix D for information on the various types of service. |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP257-0004 |
| 855 | CIP257 | TYPE-OF-SERVICE | Not Applicable | NA | Inpatient Claim/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132, or 135. (Note: In CLAIMIP, TYPE-OF-SERVICE 086 and 084 refer only to services received on an inpatient basis.) |
Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP257-0005 |
| 856 | CIP257 | TYPE-OF-SERVICE | Not Applicable | NA | Males cannot receive midwife services or other pregnancy-related procedures. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP257-0006 |
| 857 | CIP260 | SERVICING-PROV-NUM | A unique number to identify the provider who treated the recipient. |
Required | If value is invalid, record it exactly as it appears in the state system. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP260-0001 |
| 858 | CIP260 | SERVICING-PROV-NUM | Not Applicable | NA | For institutional providers and other providers operating as a group, The SERVICING-PROV-NUM should be for the individual who rendered the service. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP260-0002 |
| 859 | CIP260 | SERVICING-PROV-NUM | Not Applicable | NA | If “Servicing” provider and the “Billing” provider are the same then use the same number in both fields. |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP260-0003 |
| 860 | CIP260 | SERVICING-PROV-NUM | Not Applicable | NA | Note: Once a national provider ID numbering system is in place, the national number should be used. If only the state’s legacy ID number is available then that number can be entered in this field. |
Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP260-0004 |
| 861 | CIP260 | SERVICING-PROV-NUM | Not Applicable | NA | The value reported in SERVICING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP260-0005 |
| 862 | CIP260 | SERVICING-PROV-NUM | Not Applicable | NA | The value reported in SERVICING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP260-0007 |
| 863 | CIP260 | SERVICING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP260-0008 |
| 864 | CIP261 | SERVICING-PROV-NPI-NUM | The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The SERVICING-PROV-NPI-NUM is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. | Conditional | Valid characters include only numbers (0-9) | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP261-0001 |
| 865 | CIP261 | SERVICING-PROV-NPI-NUM | Not Applicable | NA | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP261-0002 |
| 866 | CIP262 | SERVICING-PROV-TAXONOMY | The taxonomy code for the institution billing/caring for the beneficiary. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP262-0001 |
| 867 | CIP262 | SERVICING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP262-0002 |
| 868 | CIP263 | SERVICING-PROV-TYPE | A code describing the type of provider (i.e. doctor or facility) responsible for treating a patient. This represents the attending physician if available. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided. |
Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP263-0001 |
| 869 | CIP264 | SERVICING-PROV-SPECIALTY | This code indicates the area of specialty for the servicing provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP264-0001 |
| 870 | CIP265 | OPERATING-PROV-NPI-NUM | The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary | Conditional | Valid characters include only numbers (0-9) | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP265-0001 |
| 871 | CIP265 | OPERATING-PROV-NPI-NUM | Not Applicable | NA | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP265-0002 |
| 872 | CIP266 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP266-0001 |
| 873 | CIP267 | PROV-FACILITY-TYPE | The type of facility for the servicing provider using the HIPAA provider taxonomy codes. |
Required | A value is required for CLAIMIP records | See Appendix A for listing of valid values. See Appendix N for Crosswalk of Provider Taxonomy Codes to Provider Facility Type Categories. | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP267-0001 |
| 874 | CIP268 | BENEFIT-TYPE | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System’s (MACPro’s) benefit type list. See Appendix H: Benefit Types for descriptions of the categories. |
Required | Value must be equal to a valid value. | See Appendix H for listing of valid values. | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP268-0001 |
| 875 | CIP269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | This code indicates if the claim was matched with Title XIX or Title XXI. | Required | Value must be equal to a valid value. | 01 Federal funding under Title XIX 02 Federal funding under Title XXI 03 Federal funding under ACA 04 Federal funding under other legislation |
4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP269-0001 |
| 876 | CIP269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP269-0002 |
| 877 | CIP269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for Medicaid, then any associated claims records should not have reimbursed with federal funding under Title XIX. | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP269-0003 |
| 878 | CIP270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation. | Conditional | Value must be equal to a valid value. | See Appendix I for listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP270-0001 |
| 879 | CIP270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | Not Applicable | NA | Males cannot receive services where the category of service is "Other Pregnancy-related Procedures", "Nurse Mid-wife", "Freestanding Birth Center" or "Tobacco Cessation for Pregnant Women". | Not Applicable | 4/30/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP270-0002 |
| 880 | CIP271 | XXI-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. Refer to Attachment 8 for definitions on the various categories of service. | Conditional | Value must be equal to a valid value. | See Appendix J for listing of valid values. | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP271-0001 |
| 881 | CIP272 | OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP272-0001 |
| 882 | CIP273 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP273-0001 |
| 883 | CIP273 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP273-0002 |
| 884 | CIP274 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP274-0001 |
| 885 | CIP275 | SEQUENCE-NUMBER | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' SUBMISSION-TRANSACTION-TYPE record files. | Not Applicable | 8/7/2017 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP275-0001 |
| 886 | CIP275 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | CIP275-0002 |
| 887 | CIP278 | NDC-QUANTITY | This field is to capture the actual quantity of the National Drug Code being prescribed on this in-patient claim. | Conditional | Must be numeric | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP278-0001 |
| 888 | CIP278 | NDC-QUANTITY | Not Applicable | NA | This field is only applicable when the NDC code being billed can be quantified in discrete units, e.g., the number of units of a prescription/refill that were filled. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP278-0002 |
| 889 | CIP279 | HCPCS-RATE | For inpatient hospital facility claims, the accommodation rate is captured here. This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44 (only if the value represents an accommodation rate). | Conditional | Not Applicable | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP279-0001 |
| 890 | CIP284 | NATIONAL-DRUG-CODE | A code in National Drug Code (NDC) format indicating the drug, device, or medical supply covered by this claim. | Conditional | Position 10-12 must be Alpha Numeric or blank | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP284-0001 |
| 891 | CIP284 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 1-5 must be Numeric | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP284-0002 |
| 892 | CIP284 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 6-9 must be Alpha Numeric | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP284-0003 |
| 893 | CIP284 | NATIONAL-DRUG-CODE | Not Applicable | NA | Drug code formats must be supplied by State in advance of submitting any file data. States must inform CMS of the NDC segments used and their size (e.g., {5, 4, 2} or {5, 4} as defined in the National Drug Code Directory). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP284-0004 |
| 894 | CIP284 | NATIONAL-DRUG-CODE | Not Applicable | NA | If the Drug Code is less than 11 characters in length, the value must be left justified and padded with spaces. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP284-0005 |
| 895 | CIP284 | NATIONAL-DRUG-CODE | Not Applicable | NA | If Durable Medical Equipment or supply is prescribed by a physician and provided by a pharmacy then HCPCS or state specific codes can be put in the NDC field. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP284-0006 |
| 896 | CIP284 | NATIONAL-DRUG-CODE | Not Applicable | NA | This field is applicable for pharmacy/drug and DME services that are provided to Medicaid/CHIP in an in-patient facility/setting. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP284-0007 |
| 897 | CIP285 | NDC-UNIT-OF-MEASURE | A code to indicate the basis by which the quantity of the National Drug Code is expressed. |
Conditional | Value must be equal to a valid value. Valid Value Definition: F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit |
F2 International Unit ML Milliliter GR Gram ME Milligram UN Unit |
8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP285-0001 |
| 898 | CIP285 | NDC-UNIT-OF-MEASURE | Not Applicable | NA | Enter the unit of measure for each corresponding quantity value. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP285-0002 |
| 899 | CIP286 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0001 |
| 900 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0002 |
| 901 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0003 |
| 902 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0004 |
| 903 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | If a complete, valid date is not available or is unknown, 9-fil | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0005 |
| 904 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0006 |
| 905 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or after the ADMISSION-DATE | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0007 |
| 906 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record when the eligible is not a CHIP unborn child. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0008 |
| 907 | CIP286 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 10/10/2013 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP286-0009 |
| 908 | CIP287 | SELF-DIRECTION-TYPE | This data element is not applicable to this file type. | Conditional | Value must be equal to a valid value. | 000 Not Applicable 001 Hiring Authority 002 Budget Authority 003 Hiring and Budget Authority |
8/7/2017 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP287-0001 |
| 909 | CIP288 | PRE-AUTHORIZATION-NUM | A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also called Prior Authorization or Referral Number). | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | CIP288-0001 |
| 910 | CIP289 | PROV-LOCATION-ID | A code to uniquely identify the geographic location where the provider’s services were performed. The value should correspond to an active value in the PROV-LOCATION-ID field in the provider subject area. | Required | If a particular license is applicable to all locations, create an identifier that signifies "All Locations" | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP289-0001 |
| 911 | CIP289 | PROV-LOCATION-ID | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | CIP289-0002 |
| 912 | CLT001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002 | Required | Value must be equal to a valid value. | CLT00001 | 4/30/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT001-0001 |
| 913 | CLT001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT001-0002 |
| 914 | CLT002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT002-0001 |
| 915 | CLT003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT003-0001 |
| 916 | CLT003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 917 | CLT004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or pipe-delimited format. | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
4/30/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT004-0001 |
| 918 | CLT005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document. | Not Applicable | 2/25/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT005-0001 |
| 919 | CLT006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Value must be equal to a valid value. | 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.) |
4/30/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT006-0001 |
| 920 | CLT006 | FILE-NAME | Not Applicable | NA | For TYPE-OF-SERVICE = 009, 044, 045, 046, 047, 048, 059, or 133, FILE-NAME must be CLAIM-LT | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 921 | CLT007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT007-0001 |
| 922 | CLT007 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT007-0002 |
| 923 | CLT007 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT007-0003 |
| 924 | CLT007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT007-0004 |
| 925 | CLT008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT008-0001 |
| 926 | CLT008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT008-0002 |
| 927 | CLT008 | DATE-FILE-CREATED | Not Applicable | NA | Required on every file header | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 928 | CLT008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field. | Not Applicable | 10/10/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT008-0003 |
| 929 | CLT009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT009-0001 |
| 930 | CLT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 931 | CLT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT009-0002 |
| 932 | CLT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 933 | CLT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 934 | CLT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 935 | CLT010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT010-0001 |
| 936 | CLT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT010-0002 |
| 937 | CLT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 938 | CLT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 939 | CLT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than DATE-FILE-CREATED. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 940 | CLT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be greater than START-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 941 | CLT011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT011-0001 |
| 942 | CLT011 | FILE-STATUS-INDICATOR | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 943 | CLT011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 944 | CLT012 | SSN-INDICATOR | Indicates whether the state uses the eligible person's social security number (SSN) instead of an MSIS identification number as the unique, unchanging eligible person identifier. | Required | Value must be equal to a valid value. | 0 State does not use SSN as MSIS-IDENTIFICATION-NUMBER 1 State uses SSN as MSIS-IDENTIFICATION-NUMBER |
8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT012-0001 |
| 945 | CLT012 | SSN-INDICATOR | Not Applicable | NA | A state's SSN/Non-SSN designation on the eligibility file should match on the claims files. | Not Applicable | 4/30/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT012-0002 |
| 946 | CLT012 | SSN-INDICATOR | Not Applicable | NA | For non-SSN states, the SSN-INDICATOR in the Header record must be set to 0 and the MSIS identification number must be reported in the MSIS-IDENTIFICATION-NUMBER field. If the MSIS-IDENTIFICATION-NUMBER is not known then this field should be 9-filled, left blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 947 | CLT013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT013-0001 |
| 948 | CLT013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable |
| 949 | CLT014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT014-0001 |
| 950 | CLT014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT014-0002 |
| 951 | CLT015 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT015-0001 |
| 952 | CLT016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002 | Required | Value must be equal to a valid value. | CLT00002 | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT016-0001 |
| 953 | CLT016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT016-0002 |
| 954 | CLT017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT017-0001 |
| 955 | CLT017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT017-0002 |
| 956 | CLT017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT017-0003 |
| 957 | CLT017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT017-0004 |
| 958 | CLT018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT018-0001 |
| 959 | CLT018 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT018-0002 |
| 960 | CLT018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT018-0004 |
| 961 | CLT019 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT019-0001 |
| 962 | CLT019 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT019-0002 |
| 963 | CLT019 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT019-0003 |
| 964 | CLT019 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 965 | CLT020 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT020-0001 |
| 966 | CLT020 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT020-0002 |
| 967 | CLT020 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT020-0003 |
| 968 | CLT021 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to state’s claim adjudication system. | Conditional | Value must not be null | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT021-0001 |
| 969 | CLT022 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT022-0001 |
| 970 | CLT022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the state ID numbers must be supplied to CMS | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT022-0002 |
| 971 | CLT022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For TYPE-OF-CLAIM = 4 or D (lump sum adjustments), this field must begin with an ‘&’. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT022-0003 |
| 972 | CLT022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT022-0004 |
| 973 | CLT023 | CROSSOVER-INDICATOR | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Required | Value must be equal to a valid value. | 0 Not Crossover Claim 1 Crossover Claim |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT023-0001 |
| 974 | CLT023 | CROSSOVER-INDICATOR | Not Applicable | NA | If Crossover Indicator is Yes, there must be Medicare enrollment in the Eligible file for the same time period (by date of service). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT023-0002 |
| 975 | CLT023 | CROSSOVER-INDICATOR | Not Applicable | NA | Detail records should be created for all crossover claims. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT023-0003 |
| 976 | CLT024 | 1115A-DEMONSTRATION-IND | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT024-0001 |
| 977 | CLT025 | ADJUSTMENT-IND | Code indicating the type of adjustment record. | Required | Value must be equal to a valid value. |
0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 978 | CLT025 | ADJUSTMENT-IND | Not Applicable | NA | ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "3", "5", "A", "C", "E", "U", "W", "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT025-0002 |
| 979 | CLT026 | ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT026-0001 |
| 980 | CLT026 | ADJUSTMENT-REASON-CODE | Not Applicable | NA | If there is no adjustment to a claim, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE). If claim record does not represent an adjustment,leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT026-0002 |
| 981 | CLT027 | ADMITTING-DIAGNOSIS-CODE | The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician. | Required | Code full valid ICD 9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 “. Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT027-0001 |
| 982 | CLT027 | ADMITTING-DIAGNOSIS-CODE | Not Applicable | NA | E-codes are not valid as Admitting Diagnosis Codes. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT027-0002 |
| 983 | CLT027 | ADMITTING-DIAGNOSIS-CODE | Not Applicable | NA | The diagnosis provided by the physician at the time of admission which describes the patient's condition upon admission to the hospital. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT027-0003 |
| 984 | CLT027 | ADMITTING-DIAGNOSIS-CODE | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not 8- or 9-fill. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT027-0004 |
| 985 | CLT028 | ADMITTING-DIAGNOSIS-CODE-FLAG | A flag that identifies the coding system used for the ADMITTING-DIAGNOSIS- CODE. | Required | Value must be equal to a valid value. | 01 ICD-9 02 ICD-10 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT028-0001 |
| 986 | CLT028 | ADMITTING-DIAGNOSIS-CODE-FLAG | Not Applicable | NA | The state must use a code that belongs to the code set that they report they are using. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT028-0002 |
| 987 | CLT029 | DIAGNOSIS-CODE-1 | DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-2: Primary and Second ICD-9/10-CM code found on the claim. | Required | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT029-0001 |
| 988 | CLT029 | DIAGNOSIS-CODE-1 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT029-0002 |
| 989 | CLT029 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT029-0003 |
| 990 | CLT029 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not 8-fill or 9-fill these items | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT029-0004 |
| 991 | CLT029 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT029-0005 |
| 992 | CLT029 | DIAGNOSIS-CODE-1 | Not Applicable | NA | The primary diagnosis code goes into DIAGNOSIS-CODE1 | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT029-0006 |
| 993 | CLT029 | DIAGNOSIS-CODE-1 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT029-0007 |
| 994 | CLT030 | DIAGNOSIS-CODE-FLAG-1 | A flag that identifies the coding system used for the DIAGNOSIS CODE 1 - 12 DIAGNOSIS-CODE-FLAG-1 through DIAGNOSIS-CODE-FLAG-2: Code flag for the Primary and Second ICD-9/10-CM code found on the claim. |
Required | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT030-0001 |
| 995 | CLT030 | DIAGNOSIS-CODE-FLAG-1 | Not Applicable | NA | For implementation date edits, Beginning Date of Service will be used for OT claims, and Ending Date of Service will be used for IP and LT claims. This is to be in alignment with the Medicare requirements. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT030-0002 |
| 996 | CLT030 | DIAGNOSIS-CODE-FLAG-1 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT030-0004 |
| 997 | CLT031 | DIAGNOSIS-POA-FLAG-1 | A code to identify conditions that are present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT031-0001 |
| 998 | CLT031 | DIAGNOSIS-POA-FLAG-1 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT031-0002 |
| 999 | CLT032 | DIAGNOSIS-CODE-2 | DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-2: Primary and Second ICD-9/10-CM code found on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT032-0001 |
| 1000 | CLT032 | DIAGNOSIS-CODE-2 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT032-0002 |
| 1001 | CLT032 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT032-0003 |
| 1002 | CLT032 | DIAGNOSIS-CODE-2 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT032-0004 |
| 1003 | CLT032 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not 8-fill or 9-fill these items. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT032-0005 |
| 1004 | CLT032 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT032-0006 |
| 1005 | CLT032 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Do not report duplicate diagnosis codes across DIAGNOSIS-CODE data elements 1 - 5. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT032-0007 |
| 1006 | CLT033 | DIAGNOSIS-CODE-FLAG-2 | DIAGNOSIS-CODE-FLAG-1 through DIAGNOSIS-CODE-FLAG-2: Code flag for the Primary and Second ICD-9/10-CM code found on the claim. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT033-0001 |
| 1007 | CLT033 | DIAGNOSIS-CODE-FLAG-2 | Not Applicable | NA | For implementation date edits, Beginning Date of Service will be used for OT claims, and Ending Date of Service will be used for IP and LT claims. This is to be in alignment with the Medicare requirements. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT033-0002 |
| 1008 | CLT033 | DIAGNOSIS-CODE-FLAG-2 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT033-0004 |
| 1009 | CLT034 | DIAGNOSIS-POA-FLAG-2 | A code to identify conditions that are present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT034-0001 |
| 1010 | CLT034 | DIAGNOSIS-POA-FLAG-2 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT034-0002 |
| 1011 | CLT035 | DIAGNOSIS-CODE-3 | DIAGNOSIS-CODE-3 through DIAGNOSIS-CODE-5: The third through fifth ICD-9/10-CM codes that appear on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT035-0001 |
| 1012 | CLT035 | DIAGNOSIS-CODE-3 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT035-0002 |
| 1013 | CLT035 | DIAGNOSIS-CODE-3 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT035-0003 |
| 1014 | CLT035 | DIAGNOSIS-CODE-3 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT035-0004 |
| 1015 | CLT035 | DIAGNOSIS-CODE-3 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not 8-fill or 9-fill these items. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT035-0005 |
| 1016 | CLT035 | DIAGNOSIS-CODE-3 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT035-0006 |
| 1017 | CLT035 | DIAGNOSIS-CODE-3 | Not Applicable | NA | Do not report duplicate diagnosis codes across DIAGNOSIS-CODE data elements 1 - 5. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT035-0007 |
| 1018 | CLT036 | DIAGNOSIS-CODE-FLAG-3 | DIAGNOSIS-CODE-FLAG-3 through DIAGNOSIS-CODE-FLAG-5: Code flag for the third through fifth ICD-9/10-CM codes that appear on the claim. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT036-0001 |
| 1019 | CLT036 | DIAGNOSIS-CODE-FLAG-3 | Not Applicable | NA | For implementation date edits, Beginning Date of Service will be used for OT claims, and Ending Date of Service will be used for IP and LT claims. This is to be in alignment with the Medicare requirements. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT036-0002 |
| 1020 | CLT036 | DIAGNOSIS-CODE-FLAG-3 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT036-0004 |
| 1021 | CLT037 | DIAGNOSIS-POA-FLAG-3 | A code to identify conditions that are present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT037-0001 |
| 1022 | CLT037 | DIAGNOSIS-POA-FLAG-3 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT037-0002 |
| 1023 | CLT038 | DIAGNOSIS-CODE-4 | DIAGNOSIS-CODE-3 through DIAGNOSIS-CODE-5: The third through fifth ICD-9/10-CM codes that appear on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT038-0001 |
| 1024 | CLT038 | DIAGNOSIS-CODE-4 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT038-0002 |
| 1025 | CLT038 | DIAGNOSIS-CODE-4 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT038-0003 |
| 1026 | CLT038 | DIAGNOSIS-CODE-4 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT038-0004 |
| 1027 | CLT038 | DIAGNOSIS-CODE-4 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not 8-fill or 9-fill these items. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT038-0005 |
| 1028 | CLT038 | DIAGNOSIS-CODE-4 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT038-0006 |
| 1029 | CLT038 | DIAGNOSIS-CODE-4 | Not Applicable | NA | Do not report duplicate diagnosis codes across DIAGNOSIS-CODE data elements 1 - 5. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT038-0007 |
| 1030 | CLT039 | DIAGNOSIS-CODE-FLAG-4 | DIAGNOSIS-CODE-FLAG-3 through DIAGNOSIS-CODE-FLAG-5: Code flag for the third through fifth ICD-9/10-CM codes that appear on the claim. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT039-0001 |
| 1031 | CLT039 | DIAGNOSIS-CODE-FLAG-4 | Not Applicable | NA | For implementation date edits, Beginning Date of Service will be used for OT claims, and Ending Date of Service will be used for IP and LT claims. This is to be in alignment with the Medicare requirements. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT039-0002 |
| 1032 | CLT039 | DIAGNOSIS-CODE-FLAG-4 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT039-0004 |
| 1033 | CLT040 | DIAGNOSIS-POA-FLAG-4 | A code to identify conditions that are present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT040-0001 |
| 1034 | CLT040 | DIAGNOSIS-POA-FLAG-4 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT040-0002 |
| 1035 | CLT041 | DIAGNOSIS-CODE-5 | DIAGNOSIS-CODE-3 through DIAGNOSIS-CODE-5: The third through fifth ICD-9/10-CM codes that appear on the claim. | Conditional | Code valid ICD-9/10 CM codes without a decimal point. For example: 210.5 is coded as "2105 ". |
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT041-0001 |
| 1036 | CLT041 | DIAGNOSIS-CODE-5 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT041-0002 |
| 1037 | CLT041 | DIAGNOSIS-CODE-5 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT041-0003 |
| 1038 | CLT041 | DIAGNOSIS-CODE-5 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT041-0004 |
| 1039 | CLT041 | DIAGNOSIS-CODE-5 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not 8-fill or 9-fill these items. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT041-0005 |
| 1040 | CLT041 | DIAGNOSIS-CODE-5 | Not Applicable | NA | Provide diagnosis coding as submitted on bill. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT041-0006 |
| 1041 | CLT041 | DIAGNOSIS-CODE-5 | Not Applicable | NA | Do not report duplicate diagnosis codes across DIAGNOSIS-CODE data elements 1 - 5. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT041-0007 |
| 1042 | CLT042 | DIAGNOSIS-CODE-FLAG-5 | DIAGNOSIS-CODE-FLAG-3 through DIAGNOSIS-CODE-FLAG-5: Code flag for the third through fifth ICD-9/10-CM codes that appear on the claim. | Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT042-0001 |
| 1043 | CLT042 | DIAGNOSIS-CODE-FLAG-5 | Not Applicable | NA | For implementation date edits, Beginning Date of Service will be used for OT claims, and Ending Date of Service will be used for IP and LT claims. This is to be in alignment with the Medicare requirements. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT042-0002 |
| 1044 | CLT042 | DIAGNOSIS-CODE-FLAG-5 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT042-0004 |
| 1045 | CLT043 | DIAGNOSIS-POA-FLAG-5 | A code to identify conditions that are present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
Conditional | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT043-0001 |
| 1046 | CLT043 | DIAGNOSIS-POA-FLAG-5 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT043-0002 |
| 1047 | CLT044 | ADMISSION-DATE | The date on which the recipient was admitted to a psychiatric or long-term care facility. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT044-0001 |
| 1048 | CLT044 | ADMISSION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT044-0002 |
| 1049 | CLT044 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or before the ADJUDICATION-DATE | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT044-0003 |
| 1050 | CLT044 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or before the DISCHARGE-DATE | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT044-0004 |
| 1051 | CLT044 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or after the DATE-OF-BIRTH listed in Eligible Record. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT044-0005 |
| 1052 | CLT044 | ADMISSION-DATE | Not Applicable | NA | ADMISSION-DATE should occur on or before the DATE-OF-DEATH listed in Eligible Record. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT044-0006 |
| 1053 | CLT045 | ADMISSION-HOUR | The time of admission to a psychiatric or long-term care facility. | Conditional | Value must be a valid hour in military time format (00 to 23). | See Appendix A for listing of valid values. | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT045-0001 |
| 1054 | CLT046 | DISCHARGE-DATE | The date on which the recipient was discharged from a psychiatric or long-term care facility. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT046-0001 |
| 1055 | CLT046 | DISCHARGE-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT046-0002 |
| 1056 | CLT046 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or after the ADMISSION-DATE. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT046-0003 |
| 1057 | CLT046 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or before the ADJUDICATION-DATE. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT046-0004 |
| 1058 | CLT046 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT046-0006 |
| 1059 | CLT046 | DISCHARGE-DATE | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible record | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT046-0007 |
| 1060 | CLT047 | DISCHARGE-HOUR | The time of discharge from a psychiatric or long-term care facility. | Conditional | Value must be a valid hour in military time format (00 to 23). | See Appendix A for listing of valid values. | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT047-0001 |
| 1061 | CLT048 | BEGINNING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0001 |
| 1062 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0002 |
| 1063 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before or be the same as the end of time period | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0003 |
| 1064 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as Ending Date of Service | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0004 |
| 1065 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as adjudication date. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0005 |
| 1066 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0006 |
| 1067 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before the DATE-OF-BIRTH when the person is eligible as an unborn CHIP child or beginning date of service must occur on or after the DATE-OF-BIRTH when the person is eligible through Medicaid or is eligible as a non-unborn CHIP child . | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0007 |
| 1068 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A Medicaid claim record for an eligible individual should not have a Beginning Date of Service after the eligible individual's Medicaid enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0008 |
| 1069 | CLT048 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A CHIP claim record for an individual eligible for Separate CHIP cannot have a Beginning Date of Service after the eligible individual's CHIP enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT048-0009 |
| 1070 | CLT049 | ENDING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT049-0001 |
| 1071 | CLT049 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT049-0002 |
| 1072 | CLT049 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must occur after or be the same as the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT049-0003 |
| 1073 | CLT049 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT049-0004 |
| 1074 | CLT049 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT049-0005 |
| 1075 | CLT049 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or after DATE-OF-BIRTH | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT049-0006 |
| 1076 | CLT049 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as End of Time Period. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT049-0007 |
| 1077 | CLT050 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0001 |
| 1078 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0002 |
| 1079 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0003 |
| 1080 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0004 |
| 1081 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | If a complete, valid date is not available or is unknown,leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0005 |
| 1082 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0006 |
| 1083 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or after the ADMISSION-DATE | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0007 |
| 1084 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record when the eligible is not a CHIP unborn child. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0008 |
| 1085 | CLT050 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT050-0009 |
| 1086 | CLT051 | MEDICAID-PAID-DATE | The date Medicaid paid on this claim or adjustment. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT051-0001 |
| 1087 | CLT051 | MEDICAID-PAID-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT051-0002 |
| 1088 | CLT052 | TYPE-OF-CLAIM | A code indicating what kind of payment is covered in this claim. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT052-0001 |
| 1089 | CLT052 | TYPE-OF-CLAIM | Not Applicable | NA | States should only submit CHIP claims for CHIP eligibles | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT052-0002 |
| 1090 | CLT052 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the basis of eligibility. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT052-0003 |
| 1091 | CLT052 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the maintenance assistance status. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT052-0004 |
| 1092 | CLT052 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the restricted benefits code. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT052-0005 |
| 1093 | CLT052 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the TANF code. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT052-0006 |
| 1094 | CLT053 | TYPE-OF-BILL | A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.) | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT053-0001 |
| 1095 | CLT054 | CLAIM-STATUS | The health care claim status codes convey the status of an entire claim. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT054-0001 |
| 1096 | CLT054 | CLAIM-STATUS | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1097 | CLT055 | CLAIM-STATUS-CATEGORY | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.), which is then further detailed in the companion data element CLAIM-STATUS. | Required | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT055-0001 |
| 1098 | CLT055 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All denied claims should have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1099 | CLT055 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1100 | CLT056 | SOURCE-LOCATION | The field denotes the claims payment system from which the claim was extracted. | Required | Value must be equal to a valid value. | 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) |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT056-0001 |
| 1101 | CLT057 | CHECK-NUM | The check or EFT number. |
Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT057-0001 |
| 1102 | CLT057 | CHECK-NUM | Not Applicable | NA | If there is a valid check date there should also be a valid check number. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT057-0002 |
| 1103 | CLT058 | CHECK-EFF-DATE | Date the check is issued to the payee, or if Electronic Funds Transfer (EFT), the date the transfer is made. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT058-0001 |
| 1104 | CLT058 | CHECK-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1105 | CLT058 | CHECK-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT058-0002 |
| 1106 | CLT058 | CHECK-EFF-DATE | Not Applicable | NA | Could be the same as Remittance Date. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT058-0003 |
| 1107 | CLT058 | CHECK-EFF-DATE | Not Applicable | NA | If there is a valid check number, there should also be a valid check date. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT058-0004 |
| 1108 | CLT059 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT059-0001 |
| 1109 | CLT060 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT060-0001 |
| 1110 | CLT061 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT061-0001 |
| 1111 | CLT062 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT062-0001 |
| 1112 | CLT063 | TOT-BILLED-AMT | The total amount billed for this claim at the claim header level as submitted by the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT063-0001 |
| 1113 | CLT063 | TOT-BILLED-AMT | Not Applicable | NA | The total amount should be the sum of each of the billed amounts submitted at the claim detail level. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT063-0002 |
| 1114 | CLT063 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000". | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT063-0003 |
| 1115 | CLT063 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed to the managed care plan. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT063-0004 |
| 1116 | CLT064 | TOT-ALLOWED-AMT | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT064-0001 |
| 1117 | CLT064 | TOT-ALLOWED-AMT | Not Applicable | NA | The sum of the allowed amounts at the detailed levels must equal TOT-ALLOWED-AMT | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT064-0002 |
| 1118 | CLT065 | TOT-MEDICAID-PAID-AMT | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Required | If TYPE-OF-CLAIM = 1 or A (fee-for-service claim) this field should be populated with the amount that the Medicaid agency paid to the provider. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT065-0001 |
| 1119 | CLT065 | TOT-MEDICAID-PAID-AMT | Not Applicable | NA | If TYPE‐OF‐CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT065-0002 |
| 1120 | CLT066 | TOT-COPAY-AMT | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT066-0001 |
| 1121 | CLT067 | TOT-MEDICARE-DEDUCTIBLE-AMT | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary’s Medicare deductible. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT067-0001 |
| 1122 | CLT067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code MEDICARE-COMB-DED-IND with a "1", and code space in TOT-MEDICARE-COINS-AMT. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1123 | CLT067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | The total Medicare deductible amount must be less than or equal the total billed amount. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT067-0002 |
| 1124 | CLT068 | TOT-MEDICARE-COINS-AMT | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary’s Medicare coinsurance. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT068-0001 |
| 1125 | CLT068 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | Value must be less than TOT-BILLED-AMT. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT068-0003 |
| 1126 | CLT068 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | If the Medicare coinsurance amount can be identified separately from Medicare deductible amount, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, code space in this field, code MEDICARE-COMB-DED-IND with a "1", and fill the combined payment amount in TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1127 | CLT069 | TOT-TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT069-0001 |
| 1128 | CLT069 | TOT-TPL-AMT | Not Applicable | NA | The TOT-TPL-AMT should be < ( (TOT-BILLED-AMT - (minus) TOT-MEDICARE-COINS-AMT + (plus) TOT-MEDICARE-DEDUCTIBLE-AMT) ) | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT069-0002 |
| 1129 | CLT070 | TOT-OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT070-0001 |
| 1130 | CLT071 | OTHER-INSURANCE-IND | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT071-0001 |
| 1131 | CLT072 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT072-0001 |
| 1132 | CLT073 | SERVICE-TRACKING-TYPE | A code to categorize service tracking claims. A “service tracking claim” is used to report lump sum payments that cannot be attributed to a single enrollee. (Note: Use an encounter record to report services provided under a capitated payment arrangement.) | Conditional | Value must be equal to a valid value. | 00 Not a Service Tracking Claim 01 Drug Rebate 02 DSH Payment 03 Lump Sum Payment 04 Cost Settlement 05 Supplemental 06 Other |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT073-0001 |
| 1133 | CLT073 | SERVICE-TRACKING-TYPE | Not Applicable | NA | This field is required if TYPE-OF-CLAIM equals a service tracking claim (Valid values for service tracking claims include 4, D, X) | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1134 | CLT074 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Required on service tracking records, TYPE-OF-CLAIM equals 4, D, X) | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT074-0002 |
| 1135 | CLT074 | SERVICE-TRACKING-PAYMENT-AMT | On service tracking claims, the lump sum amount paid to the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT074-0001 |
| 1136 | CLT074 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Amount paid for services received by an individual patient, when the state accepts a lump sum form a provider that covered similar services delivered to more than one patient, such as a group screening for EPSDT. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT074-0003 |
| 1137 | CLT074 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | For service tracking payments, ensure that the TOT-MEDICAID-PAID-AMOUNT is 0 filled and provide payment amount in SERVICE-TRACKING-PAYMENT-AMT only. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT074-0004 |
| 1138 | CLT074 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | If there is a service tracking type, then there must also be a service tracking payment amount. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT074-0005 |
| 1139 | CLT074 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | If SERVICE-TRACKING-TYPE <> "00" or "99", then SERVICE-TRACKING-PAYMENT-AMT must BE<> 000000000000. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT074-0006 |
| 1140 | CLT075 | FIXED-PAYMENT-IND | This code indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management (PCCM) programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined “medical record” associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Conditional | Value must be equal to a valid value. | 0 Not Fixed Payment 1 FFS Fixed Payment |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT075-0001 |
| 1141 | CLT076 | FUNDING-CODE | A code to indicate the source of non-federal share funds. | Required | Value must be equal to a valid value. | 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 |
10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT076-0001 |
| 1142 | CLT077 | FUNDING-SOURCE-NONFEDERAL-SHARE | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. | Required | Value must be equal to a valid value. When states have multiple sources of FUNDING-SOURCE-NONFEDERAL-SHARE, States are to report the portion which represents the largest proportion as the 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 |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT077-0001 |
| 1143 | CLT078 | MEDICARE-COMB-DED-IND | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. | Conditional | Value must be equal to a valid value. | 0 Amount not combined with coinsurance amount 1 Amount combined with coinsurance amount |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT078-0001 |
| 1144 | CLT078 | MEDICARE-COMB-DED-IND | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any combined deductible amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT078-0003 |
| 1145 | CLT079 | PROGRAM-TYPE | Code indicating special Medicaid program under which the service was provided. Refer to Appendix E for information on the various program types. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT079-0001 |
| 1146 | CLT079 | PROGRAM-TYPE | Not Applicable | NA | Value for 1915 (c) waiver must correspond to the values for 1915(c) waiver in the Waiver Type. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT079-0002 |
| 1147 | CLT079 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=Community First Choice (11) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 01 for the same time period. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT079-0003 |
| 1148 | CLT079 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=1915(i) (value=13) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 02 for the same time period. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT079-0004 |
| 1149 | CLT080 | PLAN-ID-NUMBER | A unique number, assigned by the state, which represents the health plan under which the non-fee-for-service encounter was provided including through the state plan and a waiver. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT080-0001 |
| 1150 | CLT080 | PLAN-ID-NUMBER | Not Applicable | NA | Use the number as it is carried in the state’s system. (TYPE-OF-CLAIM=3, C, W). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT080-0002 |
| 1151 | CLT080 | PLAN-ID-NUMBER | Not Applicable | NA | If TYPE-OF-CLAIM <> Encounter or Capitation Payment, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT080-0003 |
| 1152 | CLT080 | PLAN-ID-NUMBER | Not Applicable | NA | The managed care ID on the individual's eligible record must match that which is included on any claims records for the eligible individual. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT080-0005 |
| 1153 | CLT080 | PLAN-ID-NUMBER | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File" | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT080-0006 |
| 1154 | CLT081 | NATIONAL-HEALTH-CARE-ENTITY-ID | The national identifier of the health care entity (controlling health plan, subhealth plan, or other entity) at the most granular sub-health plan level of the Medicaid or CHIP health plan in which an individual is enrolled. (See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT081-0001 |
| 1155 | CLT081 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT081-0002 |
| 1156 | CLT081 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | This field is required for all managed care claims and encounters with dates of service on or after the mandated dates above. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT081-0003 |
| 1157 | CLT081 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | NATIONAL-HEALTH-CARE-ENTITY-IDs on managed care claims and encounters must match NATIONAL-HEALTH-CARE-ENTITY-IDs on file for the individual in the eligibility subject area or the TPL subject area | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT081-0004 |
| 1158 | CLT082 | PAYMENT-LEVEL-IND | The field denotes whether the claim payment is made at the header level or the detail level. | Required | Value must be equal to a valid value. | 1 Claim Header – Sum of Line Item payments 2 Claim Detail – Individual Line Item payments |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT082-0001 |
| 1159 | CLT082 | PAYMENT-LEVEL-IND | Not Applicable | NA | Payment fields at either the claim header or line on encounter records should be left blank. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT082-0002 |
| 1160 | CLT083 | MEDICARE-REIM-TYPE | This code indicates the type of Medicare Reimbursement. | Conditional | Value must be equal to a valid value. | 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 |
10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT083-0001 |
| 1161 | CLT083 | MEDICARE-REIM-TYPE | Not Applicable | NA | If this is a crossover Medicare claim (CROSSOVER-IND= 1), the claim must have a MEDICARE-REIM-TYPE. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT083-0002 |
| 1162 | CLT084 | NON-COV-DAYS | The number of days of institutional long-term care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered days does not refer to days not covered for any other service. | Conditional | Must contain number of non-covered days. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT084-0001 |
| 1163 | CLT084 | NON-COV-DAYS | Not Applicable | NA | The sum of Non-Covered Days and Covered Days must not exceed Total Length of Stay (Statement Covers Period - Thru Date minus Admission Date\Start of Care) for any payer sequence. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT084-0002 |
| 1164 | CLT085 | NON-COV-CHARGES | The charges for institutional long-term care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT085-0001 |
| 1165 | CLT086 | MEDICAID-COV-INPATIENT-DAYS | The number of inpatient psychiatric days covered by Medicaid on this claim. | Conditional | Populate this field with a valid numeric entry. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT086-0001 |
| 1166 | CLT086 | MEDICAID-COV-INPATIENT-DAYS | Not Applicable | NA | This field is required and only applicable when a CLAIMLT record has TYPE-OF-SERVICE = 044, 048, or 050 (inpatient mental health/psychiatric services). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT086-0002 |
| 1167 | CLT086 | MEDICAID-COV-INPATIENT-DAYS | Not Applicable | NA | This total must not be greater than double the duration between the DISCHARGE-DATE and the ADMISSION-DATE, plus one day. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT086-0003 |
| 1168 | CLT087 | CLAIM-LINE-COUNT | The total number of lines on the claim. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT087-0001 |
| 1169 | CLT087 | CLAIM-LINE-COUNT | Not Applicable | NA | If the number of claim lines is above the state-approved limit, the record will be split and the SPLIT-CLAIM-IND will equal 1. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT087-0002 |
| 1170 | CLT087 | CLAIM-LINE-COUNT | Not Applicable | NA | The claim line count should equal the sum of the claim lines for this record. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT087-0003 |
| 1171 | CLT090 | FORCED-CLAIM-IND | This code indicates if the claim was processed by forcing it through a manual override process. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT090-0001 |
| 1172 | CLT091 | HEALTH-CARE-ACQUIRED-CONDITION-IND | This code indicates whether the individual included on the claim has a Health Care Acquired Condition. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT091-0001 |
| 1173 | CLT092 | OCCURRENCE-CODE-01 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT092-0001 |
| 1174 | CLT092 | OCCURRENCE-CODE-01 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT092-0002 |
| 1175 | CLT092 | OCCURRENCE-CODE-01 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT092-0003 |
| 1176 | CLT093 | OCCURRENCE-CODE-02 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT093-0001 |
| 1177 | CLT093 | OCCURRENCE-CODE-02 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT093-0002 |
| 1178 | CLT093 | OCCURRENCE-CODE-02 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT093-0003 |
| 1179 | CLT094 | OCCURRENCE-CODE-03 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT094-0001 |
| 1180 | CLT094 | OCCURRENCE-CODE-03 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT094-0002 |
| 1181 | CLT094 | OCCURRENCE-CODE-03 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT094-0003 |
| 1182 | CLT095 | OCCURRENCE-CODE-04 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT095-0001 |
| 1183 | CLT095 | OCCURRENCE-CODE-04 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT095-0002 |
| 1184 | CLT095 | OCCURRENCE-CODE-04 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT095-0003 |
| 1185 | CLT096 | OCCURRENCE-CODE-05 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT096-0001 |
| 1186 | CLT096 | OCCURRENCE-CODE-05 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT096-0002 |
| 1187 | CLT096 | OCCURRENCE-CODE-05 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT096-0003 |
| 1188 | CLT097 | OCCURRENCE-CODE-06 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT097-0001 |
| 1189 | CLT097 | OCCURRENCE-CODE-06 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT097-0002 |
| 1190 | CLT097 | OCCURRENCE-CODE-06 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT097-0003 |
| 1191 | CLT098 | OCCURRENCE-CODE-07 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT098-0001 |
| 1192 | CLT098 | OCCURRENCE-CODE-07 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT098-0002 |
| 1193 | CLT098 | OCCURRENCE-CODE-07 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT098-0003 |
| 1194 | CLT099 | OCCURRENCE-CODE-08 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT099-0001 |
| 1195 | CLT099 | OCCURRENCE-CODE-08 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT099-0002 |
| 1196 | CLT099 | OCCURRENCE-CODE-08 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT099-0003 |
| 1197 | CLT100 | OCCURRENCE-CODE-09 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT100-0001 |
| 1198 | CLT100 | OCCURRENCE-CODE-09 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT100-0002 |
| 1199 | CLT100 | OCCURRENCE-CODE-09 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT100-0003 |
| 1200 | CLT101 | OCCURRENCE-CODE-10 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT101-0001 |
| 1201 | CLT101 | OCCURRENCE-CODE-10 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT101-0002 |
| 1202 | CLT101 | OCCURRENCE-CODE-10 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT101-0003 |
| 1203 | CLT102 | OCCURRENCE-CODE-EFF-DATE-01 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT102-0001 |
| 1204 | CLT102 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1205 | CLT102 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT102-0002 |
| 1206 | CLT102 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT102-0003 |
| 1207 | CLT102 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT102-0004 |
| 1208 | CLT102 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT102-0005 |
| 1209 | CLT102 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT102-0006 |
| 1210 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT103-0001 |
| 1211 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1212 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1213 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT103-0002 |
| 1214 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT103-0003 |
| 1215 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT103-0004 |
| 1216 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT103-0005 |
| 1217 | CLT103 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT103-0006 |
| 1218 | CLT104 | OCCURRENCE-CODE-EFF-DATE-03 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT104-0001 |
| 1219 | CLT104 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1220 | CLT104 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT104-0002 |
| 1221 | CLT104 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT104-0003 |
| 1222 | CLT104 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT104-0004 |
| 1223 | CLT104 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT104-0005 |
| 1224 | CLT104 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT104-0006 |
| 1225 | CLT105 | OCCURRENCE-CODE-EFF-DATE-04 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT105-0001 |
| 1226 | CLT105 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1227 | CLT105 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT105-0002 |
| 1228 | CLT105 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT105-0003 |
| 1229 | CLT105 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT105-0004 |
| 1230 | CLT105 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT105-0005 |
| 1231 | CLT105 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT105-0006 |
| 1232 | CLT106 | OCCURRENCE-CODE-EFF-DATE-05 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT106-0001 |
| 1233 | CLT106 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1234 | CLT106 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT106-0002 |
| 1235 | CLT106 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT106-0003 |
| 1236 | CLT106 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT106-0004 |
| 1237 | CLT106 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT106-0005 |
| 1238 | CLT106 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT106-0006 |
| 1239 | CLT107 | OCCURRENCE-CODE-EFF-DATE-06 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT107-0001 |
| 1240 | CLT107 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1241 | CLT107 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT107-0002 |
| 1242 | CLT107 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT107-0003 |
| 1243 | CLT107 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT107-0004 |
| 1244 | CLT107 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT107-0005 |
| 1245 | CLT107 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT107-0006 |
| 1246 | CLT108 | OCCURRENCE-CODE-EFF-DATE-07 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT108-0001 |
| 1247 | CLT108 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1248 | CLT108 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT108-0002 |
| 1249 | CLT108 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT108-0003 |
| 1250 | CLT108 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT108-0004 |
| 1251 | CLT108 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT108-0005 |
| 1252 | CLT108 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT108-0006 |
| 1253 | CLT109 | OCCURRENCE-CODE-EFF-DATE-08 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT109-0001 |
| 1254 | CLT109 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1255 | CLT109 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT109-0002 |
| 1256 | CLT109 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT109-0003 |
| 1257 | CLT109 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT109-0004 |
| 1258 | CLT109 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT109-0005 |
| 1259 | CLT109 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT109-0006 |
| 1260 | CLT110 | OCCURRENCE-CODE-EFF-DATE-09 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT110-0001 |
| 1261 | CLT110 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1262 | CLT110 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT110-0002 |
| 1263 | CLT110 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT110-0003 |
| 1264 | CLT110 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT110-0004 |
| 1265 | CLT110 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT110-0005 |
| 1266 | CLT110 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT110-0006 |
| 1267 | CLT111 | OCCURRENCE-CODE-EFF-DATE-10 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT111-0001 |
| 1268 | CLT111 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1269 | CLT111 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT111-0002 |
| 1270 | CLT111 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT111-0003 |
| 1271 | CLT111 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT111-0004 |
| 1272 | CLT111 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT111-0005 |
| 1273 | CLT111 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT111-0006 |
| 1274 | CLT112 | OCCURRENCE-CODE-END-DATE-01 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT112-0001 |
| 1275 | CLT112 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT112-0002 |
| 1276 | CLT112 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT112-0003 |
| 1277 | CLT112 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT112-0004 |
| 1278 | CLT112 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT112-0005 |
| 1279 | CLT112 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT112-0006 |
| 1280 | CLT113 | OCCURRENCE-CODE-END-DATE-02 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT113-0001 |
| 1281 | CLT113 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT113-0002 |
| 1282 | CLT113 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT113-0003 |
| 1283 | CLT113 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT113-0004 |
| 1284 | CLT113 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT113-0005 |
| 1285 | CLT113 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT113-0006 |
| 1286 | CLT114 | OCCURRENCE-CODE-END-DATE-03 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT114-0001 |
| 1287 | CLT114 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT114-0002 |
| 1288 | CLT114 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT114-0003 |
| 1289 | CLT114 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT114-0004 |
| 1290 | CLT114 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT114-0005 |
| 1291 | CLT114 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT114-0006 |
| 1292 | CLT115 | OCCURRENCE-CODE-END-DATE-04 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT115-0001 |
| 1293 | CLT115 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT115-0002 |
| 1294 | CLT115 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT115-0003 |
| 1295 | CLT115 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT115-0004 |
| 1296 | CLT115 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT115-0005 |
| 1297 | CLT115 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT115-0006 |
| 1298 | CLT116 | OCCURRENCE-CODE-END-DATE-05 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT116-0001 |
| 1299 | CLT116 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT116-0002 |
| 1300 | CLT116 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT116-0003 |
| 1301 | CLT116 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT116-0004 |
| 1302 | CLT116 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT116-0005 |
| 1303 | CLT116 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT116-0006 |
| 1304 | CLT117 | OCCURRENCE-CODE-END-DATE-06 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT117-0001 |
| 1305 | CLT117 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT117-0002 |
| 1306 | CLT117 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT117-0003 |
| 1307 | CLT117 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT117-0004 |
| 1308 | CLT117 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT117-0005 |
| 1309 | CLT117 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT117-0006 |
| 1310 | CLT118 | OCCURRENCE-CODE-END-DATE-07 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT118-0001 |
| 1311 | CLT118 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT118-0002 |
| 1312 | CLT118 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT118-0003 |
| 1313 | CLT118 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT118-0004 |
| 1314 | CLT118 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT118-0005 |
| 1315 | CLT118 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT118-0006 |
| 1316 | CLT119 | OCCURRENCE-CODE-END-DATE-08 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT119-0001 |
| 1317 | CLT119 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT119-0002 |
| 1318 | CLT119 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT119-0003 |
| 1319 | CLT119 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT119-0004 |
| 1320 | CLT119 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT119-0005 |
| 1321 | CLT119 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT119-0006 |
| 1322 | CLT120 | OCCURRENCE-CODE-END-DATE-09 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT120-0001 |
| 1323 | CLT120 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT120-0002 |
| 1324 | CLT120 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT120-0003 |
| 1325 | CLT120 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT120-0004 |
| 1326 | CLT120 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT120-0005 |
| 1327 | CLT120 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT120-0006 |
| 1328 | CLT121 | OCCURRENCE-CODE-END-DATE-10 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT121-0001 |
| 1329 | CLT121 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT121-0002 |
| 1330 | CLT121 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT121-0003 |
| 1331 | CLT121 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT121-0004 |
| 1332 | CLT121 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT121-0005 |
| 1333 | CLT121 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT121-0006 |
| 1334 | CLT122 | PATIENT-CONTROL-NUM | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client’s episode of service within the provider’s system to facilitate retrieval of individual financial and clinical records and posting of payment. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT122-0001 |
| 1335 | CLT123 | ELIGIBLE-LAST-NAME | The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT123-0001 |
| 1336 | CLT123 | ELIGIBLE-LAST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT123-0002 |
| 1337 | CLT124 | ELIGIBLE-FIRST-NAME | The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT124-0001 |
| 1338 | CLT124 | ELIGIBLE-FIRST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT124-0002 |
| 1339 | CLT125 | ELIGIBLE-MIDDLE-INIT | The middle initial of the individual to whom the services were provided. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT125-0001 |
| 1340 | CLT125 | ELIGIBLE-MIDDLE-INIT | Not Applicable | NA | Leave blank if not available When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than use the eligible person’s name from the T-MSIS Eligible File. |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT125-0002 |
| 1341 | CLT126 | DATE-OF-BIRTH | Date of birth of the individual to whom the services were provided. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT126-0001 |
| 1342 | CLT126 | DATE-OF-BIRTH | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT126-0002 |
| 1343 | CLT126 | DATE-OF-BIRTH | Not Applicable | NA | The numeric form for days and months from 1 to 9 must have a zero as the first digit. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT126-0003 |
| 1344 | CLT126 | DATE-OF-BIRTH | Not Applicable | NA | A patient's age should not be greater than 112 years. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT126-0005 |
| 1345 | CLT127 | HEALTH-HOME-PROV-IND | This code indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT127-0001 |
| 1346 | CLT127 | HEALTH-HOME-PROV-IND | Not Applicable | NA | If a state has not yet begun collecting this information, HEALTH-HOME-PROV-IND, this field should be defaulted to the value “8.” | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT127-0002 |
| 1347 | CLT127 | HEALTH-HOME-PROV-IND | Not Applicable | NA | If there is a HEALTH-HOME-ENTITY-NAME then HEALTH-HOME-PROV-IND must indicate yes. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT127-0003 |
| 1348 | CLT127 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States should not submit claim records for an eligible individual that indicate the claim was submitted by a provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT127-0004 |
| 1349 | CLT127 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT127-0005 |
| 1350 | CLT128 | WAIVER-TYPE | Code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Conditional | Enter the WAIVER-TYPE assigned | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT128-0001 |
| 1351 | CLT128 | WAIVER-TYPE | Not Applicable | NA | Value must correspond to associated WAIVER-ID | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT128-0002 |
| 1352 | CLT128 | WAIVER-TYPE | Not Applicable | NA | An ineligible individual cannot have a category for federal reimbursement for Medicaid or CHIP (CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT <> 01,02) | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT128-0003 |
| 1353 | CLT129 | WAIVER-ID | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. The categories of demonstration and waiver programs include: 1915(b)(1); 1915(b)(2); 1915(b)(3), and 1915(b)(4) managed care waivers; 1915(c) home and community based services waivers; combined 1915(b) and 1915(c) managed home and community based services waivers and 1115 demonstrations. | Conditional | Not Applicable | Valid values are supplied by the state. | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1354 | CLT129 | WAIVER-ID | Not Applicable | NA | Report the full federal waiver identifier. | Not Applicable | 11/9/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT129-0002 |
| 1355 | CLT129 | WAIVER-ID | Not Applicable | NA | If the goods & services rendered do not fall under a waiver, leave this field blank. | Not Applicable | 11/9/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT129-0004 |
| 1356 | CLT129 | WAIVER-ID | Not Applicable | NA | If there's a waiver type, there should be a corresponding waiver id. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT129-0005 |
| 1357 | CLT130 | BILLING-PROV-NUM | A unique identification number assigned by the state to a provider or capitation plan. This should represent the entity billing for the service. | Required | If value is invalid, record it exactly as it appears in the state system. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT130-0001 |
| 1358 | CLT130 | BILLING-PROV-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), this represents the entity billing (or reporting) to the managed care plan (See PLAN-ID-NUMBER for reporting capitation plan-ID). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT130-0002 |
| 1359 | CLT130 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT130-0003 |
| 1360 | CLT130 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT130-0004 |
| 1361 | CLT130 | BILLING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT130-0005 |
| 1362 | CLT131 | BILLING-PROV-NPI-NUM | The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care. | Required | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT131-0001 |
| 1363 | CLT131 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT131-0002 |
| 1364 | CLT131 | BILLING-PROV-NPI-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity billing (or reporting) to the managed care plan. For financial transactions (i.e., expenditure transactions or recoupments of previously made expenditures that do not flow through the usual claim adjudication/adjustment process or encounter record reporting process), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity to which the financial transaction was addressed, unless the transaction is a payment/recoupment made-to/received-from a managed care plan, in which case the BILLING-PROV-NPI-NUM should be left blank. For financial transactions with managed care plans, the plan's ID should be reported in the PLAN-ID-NUMBER field and the BILLING-PROV-NPI-NUM should be left blank. |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT131-0004 |
| 1365 | CLT131 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Billing Provider must be enrolled | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT131-0005 |
| 1366 | CLT132 | BILLING-PROV-TAXONOMY | For CLAIMIP and CLAIMLT files, the taxonomy code for the institution billing for the beneficiary. | Conditional | Value must be in the set of valid values | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT132-0001 |
| 1367 | CLT132 | BILLING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT132-0002 |
| 1368 | CLT133 | BILLING-PROV-TYPE | A code describing the type of entity billing for the service. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT133-0001 |
| 1369 | CLT133 | BILLING-PROV-TYPE | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM= 3, C, W), this represents the entity billing (or reporting) to the Managed Care Plan (see PLAN-ID-NUMBER for reporting capitation plan-ID). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT133-0002 |
| 1370 | CLT133 | BILLING-PROV-TYPE | Not Applicable | NA | The state should use Taxonomy Crosswalk.pdf to crosswalk state codes to CMS codes | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT133-0003 |
| 1371 | CLT134 | BILLING-PROV-SPECIALTY | This code describes the area of specialty for the billing provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT134-0001 |
| 1372 | CLT135 | REFERRING-PROV-NUM | A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual’s ID number, not a group identification number. | Conditional | If value is invalid, record it exactly as it appears in the State system. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT135-0001 |
| 1373 | CLT135 | REFERRING-PROV-NUM | Not Applicable | NA | If the Referring Provider Number is not available, but the physician’s Drug Enforcement Agency (DEA) ID is on the state file, then the state should use the DEA ID for this data element. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT135-0002 |
| 1374 | CLT135 | REFERRING-PROV-NUM | Not Applicable | NA | The value reported in REFERRING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT135-0003 |
| 1375 | CLT135 | REFERRING-PROV-NUM | Not Applicable | NA | The value reported in REFERRING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT135-0004 |
| 1376 | CLT135 | REFERRING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT135-0005 |
| 1377 | CLT136 | REFERRING-PROV-NPI-NUM | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | Conditional | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT136-0001 |
| 1378 | CLT136 | REFERRING-PROV-NPI-NUM | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT136-0002 |
| 1379 | CLT137 | REFERRING-PROV-TAXONOMY | For CLAIMIP and CLAIMLT files, the taxonomy code for the referring provider. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT137-0001 |
| 1380 | CLT137 | REFERRING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT137-0002 |
| 1381 | CLT138 | REFERRING-PROV-TYPE | A code describing the type of provider (i.e. doctor) who referred the patient. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided. |
NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT138-0001 |
| 1382 | CLT139 | REFERRING-PROV-SPECIALTY | This code indicates the area of specialty of the referring provider. | NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT139-0001 |
| 1383 | CLT140 | MEDICARE-HIC-NUM | Health Insurance Claim (HIC) Number as it appears on the patient’s Medicare card. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT140-0001 |
| 1384 | CLT140 | MEDICARE-HIC-NUM | Not Applicable | NA | If this is a crossover Medicare claim, the Bene must have a MEDICARE-HIC-Num. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT140-0003 |
| 1385 | CLT140 | MEDICARE-HIC-NUM | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's Medicare HIC Number does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT140-0004 |
| 1386 | CLT140 | MEDICARE-HIC-NUM | Not Applicable | NA | Claims records for an eligible individual should not indicate a valid Medicare HIC number, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT140-0005 |
| 1387 | CLT141 | PATIENT-STATUS | A code indicating the patient’s status as of the ENDING-DATE-OF-SERVICE. Values used are from UB-04. This is also referred to as discharge status. | Required | Value must be equal to a valid value. | 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 | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT141-0001 |
| 1388 | CLT141 | PATIENT-STATUS | Not Applicable | NA | If the date of death is valued, then the patient status should indicate that the patient has expired. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT141-0002 |
| 1389 | CLT141 | PATIENT-STATUS | Not Applicable | NA | Obtain the Patient Discharge Status valid value set which is published in the UB-04 Data Specifications Manual. 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 |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT141-0003 |
| 1390 | CLT143 | BMI | A key index for relating a person's body weight to their height. The body mass index (BMI) is a person's weight in kilograms (kg) divided by their height in meters (m) squared. | Optional | SI units: BMI = mass (kg) / (height(m))2 Imperial/US Customary units: BMI = mass (lb) * 703/ (height(in))2 BMI = mass (lb) * 4.88/ (height(ft))2 BMI = mass (st) * 9840/ (height(in))2 |
Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT143-0001 |
| 1391 | CLT143 | BMI | Not Applicable | NA | CMS is relieving states of the responsibility to: (a) Provide this data element. (b) Document a mitigation plan in the Source-to-Target-Mapping Matrix Addendum B whenever the data element cannot be populated all of the time. However if a state determines that it can populate the field and wishes to do so, they are encouraged to do so and will not incur any Addendum B mitigation plan documentation expectations. |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT143-0002 |
| 1392 | CLT144 | REMITTANCE-NUM | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number. |
Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT144-0001 |
| 1393 | CLT144 | REMITTANCE-NUM | Not Applicable | NA | Value must not be null | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT144-0002 |
| 1394 | CLT144 | REMITTANCE-NUM | Not Applicable | NA | If there is a remittance date, then there must also be a remittance number. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT144-0003 |
| 1395 | CLT145 | LTC-RCP-LIAB-AMT | The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT145-0001 |
| 1396 | CLT145 | LTC-RCP-LIAB-AMT | Not Applicable | NA | Not Applicable | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT145-0002 |
| 1397 | CLT146 | DAILY-RATE | The amount a policy will pay per day for a covered service. In some cases for OT claims this is referred to as a flat rate. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT146-0001 |
| 1398 | CLT147 | ICF-IID-DAYS | The number of days of intermediate care for individuals with an intellectual disability that were paid for in whole or in part by Medicaid. | Conditional | Populate this field with a valid numeric entry. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0001 |
| 1399 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | If value exceeds 99998 days, code as 99998. (e.g., code 100023 as 99998) | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0002 |
| 1400 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | ICF-IID-DAYS include every day of intermediate care facility services for individuals with an intellectual disability that is at least partially paid for by the State, even if private or third party funds are used for some portion of the payment. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0003 |
| 1401 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | ICF-IID-DAYS should be less than or equal to the length of stay. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0004 |
| 1402 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | ICF-IID-DAYS is applicable only for TYPE-OF-SERVICE = 046. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0005 |
| 1403 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | If TYPE-OF-SERVICE = Mental Hospital Services for the Aged, Inpatient Psychiatric Facility Services for Individuals <21, or Nursing Facility services, then ICF-IID-DAYS must = “88888”. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0006 |
| 1404 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | For all claims for psychiatric services or nursing facility care services (TYPE-OF-SERVICE = 009, 044, 045, 047, 048, 050, or 059), leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0007 |
| 1405 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | ICF-IID-DAYS is applicable only for TYPE-OF-SERVICE = 046. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0008 |
| 1406 | CLT147 | ICF-IID-DAYS | Not Applicable | NA | If ICF-IID-DAYS is greater than zero and less than 88887 then LEVEL-OF-CARE-STATUS in ELIGIBLE for the associated MSIS-IDENTIFIER (or SSN depending on which value is used as the unique identifier for enrollees) must be ICF/IID for the same month as the begin and end date of service. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT147-0009 |
| 1407 | CLT148 | LEAVE-DAYS | The number of days, during the period covered by Medicaid, on which the patient did not reside in the long term care facility. | Conditional | Populate this field with a valid numeric entry. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT148-0001 |
| 1408 | CLT148 | LEAVE-DAYS | Not Applicable | NA | LEAVE-DAYS is applicable only for TYPE-OF-SERVICE = 009, 045, 046, 047, 059 - Intermediate Care Facility for Individuals with Intellectual Disabilities, or Nursing Facility services. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT148-0002 |
| 1409 | CLT149 | NURSING-FACILITY-DAYS | The number of days of nursing care included in this claim that were paid for, in whole or in part, by Medicaid. Includes days during which nursing facility received partial payment for holding a bed during patient leave days. | Conditional | Populate this field with a valid numeric entry. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT149-0001 |
| 1410 | CLT149 | NURSING-FACILITY-DAYS | Not Applicable | NA | NURSING-FACILITY-DAYS include every day of nursing care services that is at least partially paid for by the state, even if private or third party funds are used for some portion of the payment. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT149-0002 |
| 1411 | CLT149 | NURSING-FACILITY-DAYS | Not Applicable | NA | If value exceeds 99998 days, code as 99998 | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT149-0003 |
| 1412 | CLT149 | NURSING-FACILITY-DAYS | Not Applicable | NA | For all claims for psychiatric services or intermediate care services for individuals with intellectual disabilities (TYPE-OF-SERVICE = 044, 046, 048, 050), leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT149-0004 |
| 1413 | CLT149 | NURSING-FACILITY-DAYS | Not Applicable | NA | The value for NURSING-FACILITY-DAYS must be less than or equal to the difference between the dates of service. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT149-0005 |
| 1414 | CLT149 | NURSING-FACILITY-DAYS | Not Applicable | NA | This field is required where the Type of Service indicates it is a Nursing Facility (009, 045, 047, or 059). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT149-0006 |
| 1415 | CLT149 | NURSING-FACILITY-DAYS | Not Applicable | NA | If NURSING-FACILITY-DAYS is greater than zero, then LEVEL-OF-CARE-STATUS in ELG088 for the associated MSIS-IDENTIFIER should be "003" (Nursing Facility) for the same month as the begin and end date of service. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT149-0008 |
| 1416 | CLT150 | SPLIT-CLAIM-IND | An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT150-0001 |
| 1417 | CLT150 | SPLIT-CLAIM-IND | Not Applicable | NA | If the claim has been split, the Transaction Handling Code indicator will indicate a Split Payment and Remittance (1000 BPR01 = U). | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT150-0002 |
| 1418 | CLT151 | BORDER-STATE-IND | This code indicates whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT151-0001 |
| 1419 | CLT153 | BENEFICIARY-COINSURANCE-AMOUNT | The amount of money the beneficiary paid towards coinsurance. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT153-0001 |
| 1420 | CLT153 | BENEFICIARY-COINSURANCE-AMOUNT | Not Applicable | NA | If no coinsurance is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT153-0002 |
| 1421 | CLT154 | BENEFICIARY-COINSURANCE-DATE-PAID | The date the beneficiary paid the coinsurance amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT154-0001 |
| 1422 | CLT154 | BENEFICIARY-COINSURANCE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT154-0002 |
| 1423 | CLT154 | BENEFICIARY-COINSURANCE-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT154-0003 |
| 1424 | CLT155 | BENEFICIARY-COPAYMENT-AMOUNT | The amount of money the beneficiary paid towards a copayment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT155-0001 |
| 1425 | CLT155 | BENEFICIARY-COPAYMENT-AMOUNT | Not Applicable | NA | If no copayment is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT155-0002 |
| 1426 | CLT156 | BENEFICIARY-COPAYMENT-DATE-PAID | The date the beneficiary paid the copayment amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT156-0001 |
| 1427 | CLT156 | BENEFICIARY-COPAYMENT-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT156-0002 |
| 1428 | CLT156 | BENEFICIARY-COPAYMENT-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, 8-fill, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT156-0003 |
| 1429 | CLT157 | BENEFICIARY-DEDUCTIBLE-AMOUNT | The amount of money the beneficiary paid towards an annual deductible. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT157-0001 |
| 1430 | CLT157 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Not Applicable | NA | If no deductible is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT157-0002 |
| 1431 | CLT158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | The date the beneficiary paid the deductible amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT158-0001 |
| 1432 | CLT158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT158-0002 |
| 1433 | CLT158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT158-0003 |
| 1434 | CLT159 | CLAIM-DENIED-INDICATOR | An indicator to identify a claim that the state refused pay in its entirety. | Conditional | Value must be equal to a valid value. | 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. |
11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT159-0001 |
| 1435 | CLT159 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | It is expected that states will submit all denied claims to CMS. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT159-0002 |
| 1436 | CLT159 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All denied claims should have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT159-0003 |
| 1437 | CLT159 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1438 | CLT160 | COPAY-WAIVED-IND | An indicator signifying that the copay was waived by the provider. | Optional | Value must be equal to a valid value. | 0 Not Waived: The provider did not waive the beneficiary’s copayment 1 Waived: The provider waived the beneficiary’s copayment |
8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT160-0001 |
| 1439 | CLT161 | HEALTH-HOME-ENTITY-NAME | A free-form text field to indicate the health home that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A “Health Home Entity” can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities’ names are being used instead. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT161-0001 |
| 1440 | CLT161 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's health home entity name does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT161-0002 |
| 1441 | CLT163 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item. | Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT163-0001 |
| 1442 | CLT164 | THIRD-PARTY-COINSURANCE-DATE-PAID | The date the third party paid the coinsurance amount. | Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT164-0001 |
| 1443 | CLT164 | THIRD-PARTY-COINSURANCE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT164-0002 |
| 1444 | CLT165 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | The amount the third party paid toward the copayment amount. | Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT165-0001 |
| 1445 | CLT166 | THIRD-PARTY-COPAYMENT-DATE-PAID | The date the third party paid the copayment amount | Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT166-0001 |
| 1446 | CLT166 | THIRD-PARTY-COPAYMENT-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT166-0002 |
| 1447 | CLT167 | HEALTH-HOME-PROVIDER-NPI | The National Provider ID (NPI) of the health home provider. | Conditional | The value must be a valid NPI | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT167-0001 |
| 1448 | CLT167 | HEALTH-HOME-PROVIDER-NPI | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT167-0002 |
| 1449 | CLT168 | MEDICARE-BENEFICIARY-IDENTIFIER | The individual’s Medicare Beneficiary Identifier (MBI) Identification Number. Note: MBI replaces the HICN with an entirely new Medicare Beneficiary Identifier (MBI) for purposes of provider billing, if applicable. CMS interfaces with non-payment exchange partners would remain HICN-based, while interfaces with payment partners would use the new MBI. |
NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT168-0001 |
| 1450 | CLT168 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | If individual is NOT enrolled in Medicare, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT168-0002 |
| 1451 | CLT168 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) until such time as the Medicare Beneficiary Identifier is implemented (no target date has been established). | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT168-0003 |
| 1452 | CLT169 | UNDER-DIRECTION-OF-PROV-NPI | The National Provider ID (NPI) of the provider who directed the care of a patient that another provider administered. | NA | The value must be a valid NPI | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT169-0001 |
| 1453 | CLT169 | UNDER-DIRECTION-OF-PROV-NPI | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). This data element is a duplicate of the “UNDER-SUPERVISION-OF-PROV-NPI” field and as such do not need to be populated. | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT169-0002 |
| 1454 | CLT170 | UNDER-DIRECTION-OF-PROV-TAXONOMY | The Provider Taxonomy of the provider who directed the care of a patient that another provider administered. | NA | Must be in the set of valid values | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT170-0001 |
| 1455 | CLT170 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT170-0002 |
| 1456 | CLT170 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT170-0003 |
| 1457 | CLT170 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). This data element is a duplicate of the “UNDER-SUPERVISION-OF-PROV-TAXONOMY” field and as such do not need to be populated. | Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT170-0004 |
| 1458 | CLT171 | UNDER-SUPERVISION-OF-PROV-NPI | The National Provider ID (NPI) of the provider who supervised another provider. | NA | Not Applicable | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable |
| 1459 | CLT171 | UNDER-SUPERVISION-OF-PROV-NPI | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT171-0002 |
| 1460 | CLT172 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | The Provider Taxonomy of the provider who supervised another provider. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT172-0001 |
| 1461 | CLT172 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT172-0002 |
| 1462 | CLT172 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT172-0003 |
| 1463 | CLT173 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT173-0001 |
| 1464 | CLT173 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT173-0002 |
| 1465 | CLT174 | ADMITTING-PROV-NPI-NUM | The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | Conditional | Valid characters include only numbers (0-9) | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT174-0001 |
| 1466 | CLT174 | ADMITTING-PROV-NPI-NUM | Not Applicable | NA | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT174-0002 |
| 1467 | CLT175 | ADMITTING-PROV-NUM | The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | Required | A list of valid codes must be supplied by the state prior to submission of any file data | Valid values are supplied by the state. | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT175-0001 |
| 1468 | CLT175 | ADMITTING-PROV-NUM | Not Applicable | NA | If value is invalid, record it exactly as it appears in the state system | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT175-0002 |
| 1469 | CLT175 | ADMITTING-PROV-NUM | Not Applicable | NA | Note: Once a national provider ID numbering system is in place, the national number should be used. If the State’s legacy ID number is also available then that number can be entered in this field. |
Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT175-0003 |
| 1470 | CLT175 | ADMITTING-PROV-NUM | Not Applicable | NA | The value reported in ADMITTING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT175-0004 |
| 1471 | CLT175 | ADMITTING-PROV-NUM | Not Applicable | NA | The value reported in ADMITTING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT175-0005 |
| 1472 | CLT176 | ADMITTING-PROV-SPECIALTY | This code describes the area of specialty for the admitting provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT176-0001 |
| 1473 | CLT177 | ADMITTING-PROV-TAXONOMY | The taxonomy code for the admitting provider. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT177-0001 |
| 1474 | CLT177 | ADMITTING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT177-0002 |
| 1475 | CLT178 | ADMITTING-PROV-TYPE | A code describing the type of admitting provider. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided. |
Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT178-0001 |
| 1476 | CLT179 | MEDICARE-PAID-AMT | The amount paid by Medicare on this claim or adjustment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT179-0001 |
| 1477 | CLT179 | MEDICARE-PAID-AMT | Not Applicable | NA | If the service was covered by Medicare but Medicare had no liability for the bill, zero-fill. MEDICARE-PAID-AMT should reflect the actual amount paid by Medicare. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT179-0002 |
| 1478 | CLT179 | MEDICARE-PAID-AMT | Not Applicable | NA | For claims where Medicare payment is only available at the header level, report the entire payment amount the T-MSIS record corresponding to the line item with the highest charge. Zero fill Medicare Amount Paid on all other T-MSIS records created from the original claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT179-0003 |
| 1479 | CLT179 | MEDICARE-PAID-AMT | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT179-0004 |
| 1480 | CLT183 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT183-0001 |
| 1481 | CLT184 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002 | Required | Value must be equal to a valid value. | CLT00003 | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT184-0001 |
| 1482 | CLT184 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT184-0002 |
| 1483 | CLT185 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT185-0001 |
| 1484 | CLT185 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT185-0002 |
| 1485 | CLT185 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT185-0003 |
| 1486 | CLT185 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT185-0004 |
| 1487 | CLT186 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT186-0001 |
| 1488 | CLT186 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT186-0002 |
| 1489 | CLT186 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT186-0004 |
| 1490 | CLT187 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT187-0001 |
| 1491 | CLT187 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the state ID numbers must be supplied to CMS | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT187-0002 |
| 1492 | CLT187 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For TYPE-OF-CLAIM = 4 or D (lump sum adjustments), this field must begin with an ‘&’. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT187-0003 |
| 1493 | CLT187 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT187-0004 |
| 1494 | CLT188 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT188-0001 |
| 1495 | CLT188 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT188-0002 |
| 1496 | CLT188 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT188-0003 |
| 1497 | CLT188 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable |
| 1498 | CLT189 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT189-0001 |
| 1499 | CLT189 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT189-0002 |
| 1500 | CLT189 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT189-0003 |
| 1501 | CLT190 | LINE-NUM-ORIG | A unique number to identify the transaction line number that is being reported on the original claim. | Required | Record the value exactly as it appears in the State system. Do not pad. This field should also be completed on adjustment claims to reflect the LINE-NUMBER of the INTERNAL-CONTROL-NUMBER on the claim that is being adjusted. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT190-0001 |
| 1502 | CLT191 | LINE-NUM-ADJ | A unique number to identify the transaction line number that identifies the line number on the adjustment ICN. | Conditional | Record the value exactly as it appears in the state system. Do not pad. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT191-0001 |
| 1503 | CLT191 | LINE-NUM-ADJ | Not Applicable | NA | This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number. |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT191-0002 |
| 1504 | CLT192 | LINE-ADJUSTMENT-IND | Code indicating type of adjustment record claim/encounter represents at claim detail level. | Conditional | Value must be equal to a valid value. | 0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT192-0001 |
| 1505 | CLT192 | LINE-ADJUSTMENT-IND | Not Applicable | NA | If there is a line adjustment number, then there must be a line-adjustment indicator. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT192-0002 |
| 1506 | CLT192 | LINE-ADJUSTMENT-IND | Not Applicable | NA | If there is a line adjustment reason, then there must be a line adjustment indicator. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT192-0003 |
| 1507 | CLT192 | LINE-ADJUSTMENT-IND | Not Applicable | NA | Value must be equal to a valid value. ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "3", "5", "A", "C", "E", "U", "W", "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT192-0004 |
| 1508 | CLT193 | LINE-ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT193-0001 |
| 1509 | CLT193 | LINE-ADJUSTMENT-REASON-CODE | Not Applicable | NA | If there is no adjustment to a line, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE) | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT193-0002 |
| 1510 | CLT194 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to state’s claim adjudication system. | Conditional | Value must not be null | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT194-0001 |
| 1511 | CLT195 | CLAIM-LINE-STATUS | The claim line status codes identify the status of a specific detail claim line rather than the entire claim. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT195-0001 |
| 1512 | CLT196 | BEGINNING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days or periods of care extending over two or more days, the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0001 |
| 1513 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0002 |
| 1514 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before or be the same as the ending date of service. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0003 |
| 1515 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before or be the same as the end of time period. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0004 |
| 1516 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as adjudication date. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0005 |
| 1517 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0006 |
| 1518 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or after Date of Birth | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0007 |
| 1519 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A Medicaid claim record for an eligible individual should not have a Beginning Date of Service after the eligible individual's Medicaid enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0008 |
| 1520 | CLT196 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A CHIP claim record for an individual eligible for Separate CHIP cannot have a Beginning Date of Service after the eligible individual's CHIP enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT196-0009 |
| 1521 | CLT197 | ENDING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT197-0001 |
| 1522 | CLT197 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT197-0002 |
| 1523 | CLT197 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT197-0004 |
| 1524 | CLT197 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death, when a DATE-OF-DEATH is not unknown or not applicable. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT197-0005 |
| 1525 | CLT197 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or after DATE-OF-BIRTH | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT197-0006 |
| 1526 | CLT197 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as End of Time Period. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT197-0007 |
| 1527 | CLT198 | REVENUE-CODE | A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing Manual). | Required | Only valid codes as defined by the “National Uniform Billing Committee” should be used. | Revenue code is a data set that health care providers or insurers usually pay for to use. These values will change annually. | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT198-0001 |
| 1528 | CLT198 | REVENUE-CODE | Not Applicable | NA | Enter all UB-04 Revenue Codes listed on the claim | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT198-0002 |
| 1529 | CLT198 | REVENUE-CODE | Not Applicable | NA | Value must be a valid code | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT198-0003 |
| 1530 | CLT198 | REVENUE-CODE | Not Applicable | NA | If value invalid, record it exactly as it appears in the state system | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT198-0004 |
| 1531 | CLT201 | IMMUNIZATION-TYPE | This field identifies the type of immunization provided in order to track additional detail not currently contained in CPT codes. | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT201-0001 |
| 1532 | CLT202 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. | NA | Must be numeric | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT202-0001 |
| 1533 | CLT202 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT202-0002 |
| 1534 | CLT202 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | Not Applicable | NA | For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT202-0003 |
| 1535 | CLT203 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. | NA | Must be numeric | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT203-0001 |
| 1536 | CLT203 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT203-0002 |
| 1537 | CLT203 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | Not Applicable | NA | For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT203-0003 |
| 1538 | CLT204 | REVENUE-CHARGE | The total charge for the related UB-04 Revenue Code (REVENUE-CODE) for the billing period. Total charges include both covered and non-covered charges (as defined by UB-04 Billing Manual. | Required | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT204-0001 |
| 1539 | CLT204 | REVENUE-CHARGE | Not Applicable | NA | Enter charge for each UB-04 Revenue Code listed on the claim | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT204-0002 |
| 1540 | CLT204 | REVENUE-CHARGE | Not Applicable | NA | The total amount should be the sum of each of the charged amounts submitted at the claim detail level | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT204-0003 |
| 1541 | CLT204 | REVENUE-CHARGE | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should either be zero-filled or contain the amount paid by the plan to the provider. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT204-0004 |
| 1542 | CLT204 | REVENUE-CHARGE | Not Applicable | NA | The sum of claim line charges (REVENUE-CHARGE) should be less than or equal to absolute value of TOT-BILLED-AMT. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT204-0005 |
| 1543 | CLT204 | REVENUE-CHARGE | Not Applicable | NA | Value must be left blank or space-filled if the revenue code is left blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT204-0006 |
| 1544 | CLT204 | REVENUE-CHARGE | Not Applicable | NA | Value must not be left blank or space-filled if the revenue code is not left blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT204-0007 |
| 1545 | CLT205 | ALLOWED-AMT | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT205-0001 |
| 1546 | CLT206 | TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT206-0001 |
| 1547 | CLT207 | OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT207-0001 |
| 1548 | CLT208 | MEDICAID-PAID-AMT | The amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim detail level. | Required | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT208-0001 |
| 1549 | CLT208 | MEDICAID-PAID-AMT | Not Applicable | NA | For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT208-0002 |
| 1550 | CLT208 | MEDICAID-PAID-AMT | Not Applicable | NA | For Crossover claims with Medicare Coinsurance and/or Deductibles, enter the sum of those amounts in the Medicaid-Amount-Paid field, if the providers were reimbursed by Medicaid for them. If the Coinsurance and Deductibles were not paid by the state, then report the MEDICAID-PAID-AMT as $0 | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT208-0003 |
| 1551 | CLT209 | MEDICAID-FFS-EQUIVALENT-AMT | The MEDICAID-FFS-EQUIVALENT-AMT field should be populated with the amount that would have been paid had the services been provided on a FFS basis. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT209-0001 |
| 1552 | CLT209 | MEDICAID-FFS-EQUIVALENT-AMT | Not Applicable | NA | Required when TYPE-OF-CLAIM = C, 3, or W | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT209-0002 |
| 1553 | CLT210 | BILLING-UNIT | Unit of billing that is used for billing services by the facility. | Conditional | Value must be equal to a valid value. | 01 Per Day 02 Per Hour 03 Per Case 04 Per Encounter 05 Per Week 06 Per Month 07 Other Arrangements |
8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT210-0001 |
| 1554 | CLT211 | TYPE-OF-SERVICE | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT211-0001 |
| 1555 | CLT211 | TYPE-OF-SERVICE | Not Applicable | NA | All claims for inpatient psychiatric care provided in a separately administered psychiatric wing or psychiatric hospital are included in the CLAIMLT file. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT211-0002 |
| 1556 | CLT211 | TYPE-OF-SERVICE | Not Applicable | NA | Experience has demonstrated there can be instances when more than one service area category could be applicable for a provided service. The following hierarchy rules apply to these instances: The specific service categories of sterilizations and other pregnancy-related procedures take precedence over provider categories, such as inpatient hospital or outpatient hospital. Services of a physician employed by a clinic are reported under clinic services if the clinic is the billing entity. X-rays processed by the clinic in the course of treatment, however, are reported under X-ray services. Services of a registered nurse attending a resident in a NF are reported (if they qualified under the coverage rules) under home health services if they were not billed as part of the NF bill. |
Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT211-0003 |
| 1557 | CLT211 | TYPE-OF-SERVICE | Not Applicable | NA | See Appendix D for information on the various types of service. |
Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT211-0004 |
| 1558 | CLT211 | TYPE-OF-SERVICE | Not Applicable | NA | Long Term Care Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 009, 044, 045, 046, 047, 048, 050, 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.) |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT211-0005 |
| 1559 | CLT212 | SERVICING-PROV-NUM | A unique number to identify the provider who treated the recipient. |
Required | If value is invalid, record it exactly as it appears in the state system. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT212-0001 |
| 1560 | CLT212 | SERVICING-PROV-NUM | Not Applicable | NA | If “Servicing” provider and the “Billing” provider are the same then use the same number in both fields. |
Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT212-0002 |
| 1561 | CLT212 | SERVICING-PROV-NUM | Not Applicable | NA | Note: Once a national provider ID numbering system is in place, the national number should be used. If only the state’s legacy ID number is available then that number can be entered in this field. |
Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT212-0003 |
| 1562 | CLT212 | SERVICING-PROV-NUM | Not Applicable | NA | The value reported in SERVICING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT212-0004 |
| 1563 | CLT212 | SERVICING-PROV-NUM | Not Applicable | NA | The value reported in SERVICING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT212-0006 |
| 1564 | CLT212 | SERVICING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT212-0007 |
| 1565 | CLT213 | SERVICING-PROV-NPI-NUM | The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The SERVICING-PROV-NPI-NUM is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. | Conditional | Valid characters include only numbers (0-9) | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT213-0001 |
| 1566 | CLT213 | SERVICING-PROV-NPI-NUM | Not Applicable | NA | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT213-0002 |
| 1567 | CLT214 | SERVICING-PROV-TAXONOMY | The taxonomy code for the institution billing/caring for the beneficiary. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT214-0001 |
| 1568 | CLT214 | SERVICING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT214-0003 |
| 1569 | CLT215 | SERVICING-PROV-TYPE | A code describing the type of provider (i.e. doctor or facility) responsible for treating a patient. This represents the attending physician if available. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided. |
Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT215-0001 |
| 1570 | CLT216 | SERVICING-PROV-SPECIALTY | This code indicates the area of specialty for the servicing provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT216-0001 |
| 1571 | CLT217 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT217-0001 |
| 1572 | CLT218 | BENEFIT-TYPE | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System’s (MACPro’s) benefit type list. See Appendix H: Benefit Types for descriptions of the categories. |
Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 2/25/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT218-0001 |
| 1573 | CLT219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | This code indicates if the claim was matched with Title XIX or Title XXI. | Required | Value must be equal to a valid value. | 01 Federal funding under Title XIX 02 Federal funding under Title XXI 03 Federal funding under ACA 04 Federal funding under other legislation |
8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT219-0001 |
| 1574 | CLT219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT219-0002 |
| 1575 | CLT219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for Medicaid, then any associated claims records should not have reimbursed with federal funding under Title XIX. | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT219-0003 |
| 1576 | CLT221 | PROV-FACILITY-TYPE | The type of facility for the servicing provider using the HIPAA provider taxonomy codes. | Required | A value is required for CLAIMLT records | See Appendix A for listing of valid values. See Appendix N for Crosswalk of Provider Taxonomy Codes to Provider Facility Type Categories. | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT221-0001 |
| 1577 | CLT224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation | Conditional | Value must be equal to a valid value. | See Appendix I for listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT224-0001 |
| 1578 | CLT224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | Not Applicable | NA | Males cannot receive services where the category of service is "Other Pregnancy-related Procedures", "Nurse Mid-wife", "Freestanding Birth Center" or "Tobacco Cessation for Pregnant Women". | Not Applicable | 4/30/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT224-0002 |
| 1579 | CLT225 | XXI-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. Refer to Attachment 8 for definitions on the various categories of service. | Conditional | Value must be equal to a valid value. | See Appendix J for listing of valid values. | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT225-0001 |
| 1580 | CLT226 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT226-0001 |
| 1581 | CLT226 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT226-0002 |
| 1582 | CLT227 | SEQUENCE-NUMBER | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' SUBMISSION-TRANSACTION-TYPE record files. | Not Applicable | 8/7/2017 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT227-0001 |
| 1583 | CLT227 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | CLT227-0002 |
| 1584 | CLT228 | NATIONAL-DRUG-CODE | A code in National Drug Code (NDC) format indicating the drug, device, or medical supply covered by this claim. | Conditional | Position 10-12 must be Alpha Numeric or blank | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT228-0001 |
| 1585 | CLT228 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 1-5 must be Numeric | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT228-0002 |
| 1586 | CLT228 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 6-9 must be Alpha Numeric | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT228-0003 |
| 1587 | CLT228 | NATIONAL-DRUG-CODE | Not Applicable | NA | Drug code formats must be supplied by State in advance of submitting any file data. States must inform CMS of the NDC segments used and their size (e.g., {5, 4, 2} or {5, 4} as defined in the National Drug Code Directory). | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT228-0004 |
| 1588 | CLT228 | NATIONAL-DRUG-CODE | Not Applicable | NA | If the Drug Code is less than 11 characters in length, the value must be left justified and padded with spaces. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT228-0005 |
| 1589 | CLT228 | NATIONAL-DRUG-CODE | Not Applicable | NA | If Durable Medical Equipment or supply is prescribed by a physician and provided by a pharmacy then HCPCS or state specific codes can be put in the NDC field. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT228-0006 |
| 1590 | CLT228 | NATIONAL-DRUG-CODE | Not Applicable | NA | This field is applicable for pharmacy/drug and DME services that are provided to Medicaid/CHIP recipients living in a long-term care facility. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT228-0007 |
| 1591 | CLT229 | NDC-UNIT-OF-MEASURE | A code to indicate the basis by which the quantity of the National Drug Code is expressed. |
Conditional | Value must be equal to a valid value. Valid Value Definition: F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit |
F2 International Unit ML Milliliter GR Gram ME Milligram UN Unit |
8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT229-0001 |
| 1592 | CLT229 | NDC-UNIT-OF-MEASURE | Not Applicable | NA | Enter the unit of measure for each corresponding quantity value. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT229-0002 |
| 1593 | CLT230 | NDC-QUANTITY | This field is to capture the actual quantity of the National Drug Code being prescribed on this long term care claim. | Conditional | Must be numeric | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT230-0001 |
| 1594 | CLT230 | NDC-QUANTITY | Not Applicable | NA | This field is only applicable when the NDC code being billed can be quantified in discrete units, e.g., the number of units of a prescription/refill that were filled. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT230-0002 |
| 1595 | CLT231 | HCPCS-RATE | For inpatient hospital facility claims, the accommodation rate is captured here. This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44 (only if the value represents an accommodation rate) | Conditional | Must be numeric | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT231-0001 |
| 1596 | CLT233 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0001 |
| 1597 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0002 |
| 1598 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0003 |
| 1599 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0004 |
| 1600 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | If a complete, valid date is not available or is unknown, 9-fil | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0005 |
| 1601 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0006 |
| 1602 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or after the ADMISSION-DATE | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0007 |
| 1603 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0008 |
| 1604 | CLT233 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT233-0009 |
| 1605 | CLT234 | SELF-DIRECTION-TYPE | This data element is not applicable to this file type. | Conditional | Value must be equal to a valid value. | 000 Not Applicable 001 Hiring Authority 002 Budget Authority 003 Hiring and Budget Authority |
8/7/2017 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT234-0001 |
| 1606 | CLT235 | PRE-AUTHORIZATION-NUM | A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also called Prior Authorization or Referral Number). | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT235-0001 |
| 1607 | CLT237 | PROV-LOCATION-ID | A code to uniquely identify the geographic location where the provider’s services were performed. The value should correspond to an active value in the PROV-LOCATION-ID field in the provider subject area. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT237-0001 |
| 1608 | CLT237 | PROV-LOCATION-ID | Not Applicable | NA | The value should correspond with one of the location identifiers recorded in the provider’s demographic records in the T-MSIS data set. If a particular license is applicable to all locations, create an identifier that signifies "All Locations" | Not Applicable | 8/7/2017 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | CLT237-0002 |
| 1609 | CLT238 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | CLT238-0001 |
| 1610 | COT001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002 | Required | Value must be equal to a valid value. | COT00001 | 4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT001-0001 |
| 1611 | COT001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT001-0002 |
| 1612 | COT002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT002-0001 |
| 1613 | COT003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT003-0001 |
| 1614 | COT003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1615 | COT004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or pipe-delimited format. | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT004-0001 |
| 1616 | COT005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document | Not Applicable | 2/25/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT005-0001 |
| 1617 | COT006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Value must be equal to a valid value. | CLAIM-OT - Other Claims/Encounters File - Claims/encounters with any TYPE-OF-SERVICE code 002, 003, 004, 005, 006, 007, 008, 010, 011, 012, 013, 014, 015, 016, 017, 018, 019, 020, 021, 022, 023, 024, 025, 026, 027, 028, 029, 030, 031, 032, 035, 036, 037, 038, 039, 040, 041, 042, 043, 049, 050, 051, 052, 053, 054, 055, 056, 057, 060, 061, 062, 063, 064, 065, 066, 067, 068, 069, 070, 071, 072, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083, 084, 085, 086, 087, 088, 089, 115, 119, 120, 121, 122, 123, 127, 131, 134, or 135. | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT006-0001 |
| 1618 | COT006 | FILE-NAME | Not Applicable | NA | For TYPE-OF-SERVICE = 002, 003, 004, 005, 006, 007, 008, 010, 011, 012, 013, 014, 015, 016, 017, 018, 019, 020, 021, 022, 023, 024, 025, 026, 027, 028, 029, 030, 031, 032, 035, 036, 037, 038, 039, 040, 041, 042, 043, 049, 050, 051, 052, 053, 054, 055, 056, 057, 060, 061, 062, 063, 064, 065, 066, 067, 068, 069, 070, 071, 072, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083, 084, 085, 086, 087, 088, 089, 115, 119, 120, 121, 122, 123, 127, 131, 134, or 135, FILE-NAME must be CLAIM-OT | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1619 | COT007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT007-0001 |
| 1620 | COT007 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT007-0002 |
| 1621 | COT007 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT007-0003 |
| 1622 | COT007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT007-0004 |
| 1623 | COT008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT008-0001 |
| 1624 | COT008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT008-0002 |
| 1625 | COT008 | DATE-FILE-CREATED | Not Applicable | NA | Required on every file header | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1626 | COT008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field. | Not Applicable | 4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT008-0003 |
| 1627 | COT009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT009-0001 |
| 1628 | COT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1629 | COT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT009-0002 |
| 1630 | COT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1631 | COT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1632 | COT009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1633 | COT010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT010-0001 |
| 1634 | COT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT010-0002 |
| 1635 | COT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1636 | COT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1637 | COT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than DATE-FILE-CREATED. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1638 | COT010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be greater than START-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1639 | COT011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT011-0001 |
| 1640 | COT011 | FILE-STATUS-INDICATOR | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1641 | COT011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1642 | COT012 | SSN-INDICATOR | Indicates whether the state uses the eligible person's social security number (SSN) instead of an MSIS identification number as the unique, unchanging eligible person identifier. | Required | Value must be equal to a valid value. | 0 State does not use SSN as MSIS-IDENTIFICATION-NUMBER 1 State uses SSN as MSIS-IDENTIFICATION-NUMBER |
4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT012-0001 |
| 1643 | COT012 | SSN-INDICATOR | Not Applicable | NA | A state's SSN/Non-SSN designation on the eligibility file should match on the claims files. | Not Applicable | 4/30/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT012-0002 |
| 1644 | COT012 | SSN-INDICATOR | Not Applicable | NA | For non-SSN states, the SSN-INDICATOR in the Header record must be set to 0 and the MSIS identification number must be reported in the MSIS-IDENTIFICATION-NUMBER field. If the MSIS-IDENTIFICATION-NUMBER is not known then this field should be 9-filled, left blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1645 | COT013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT013-0001 |
| 1646 | COT013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable |
| 1647 | COT014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT014-0001 |
| 1648 | COT014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT014-0002 |
| 1649 | COT015 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT015-0001 |
| 1650 | COT016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002 | Required | Value must be equal to a valid value. | COT00002 | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT016-0001 |
| 1651 | COT016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT016-0002 |
| 1652 | COT017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT017-0001 |
| 1653 | COT017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT017-0002 |
| 1654 | COT017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT017-0003 |
| 1655 | COT017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT017-0004 |
| 1656 | COT018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT018-0001 |
| 1657 | COT018 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT018-0002 |
| 1658 | COT018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT018-0004 |
| 1659 | COT019 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT019-0001 |
| 1660 | COT019 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT019-0002 |
| 1661 | COT019 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT019-0003 |
| 1662 | COT019 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1663 | COT020 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT020-0001 |
| 1664 | COT020 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT020-0002 |
| 1665 | COT020 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT020-0003 |
| 1666 | COT021 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to state’s claim adjudication system. | Conditional | Value must not be null | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT021-0001 |
| 1667 | COT022 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT022-0001 |
| 1668 | COT022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the state ID numbers must be supplied to CMS | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT022-0002 |
| 1669 | COT022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For TYPE-OF-CLAIM = 4 or D (lump sum adjustments), this field must begin with an ‘&’. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT022-0003 |
| 1670 | COT022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT022-0004 |
| 1671 | COT022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT022-0005 |
| 1672 | COT023 | CROSSOVER-INDICATOR | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Required | Value must be equal to a valid value. | 0 Not Crossover Claim 1 Crossover Claim |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT023-0001 |
| 1673 | COT023 | CROSSOVER-INDICATOR | Not Applicable | NA | If Crossover Indicator is Yes, there must be Medicare enrollment in the Eligible file for the same time period (by date of service). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT023-0002 |
| 1674 | COT023 | CROSSOVER-INDICATOR | Not Applicable | NA | Detail records should be created for all crossover claims. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT023-0003 |
| 1675 | COT024 | 1115A-DEMONSTRATION-IND | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT024-0001 |
| 1676 | COT025 | ADJUSTMENT-IND | Code indicating the type of adjustment record. | Required | Value must be equal to a valid value. |
0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT025-0001 |
| 1677 | COT025 | ADJUSTMENT-IND | Not Applicable | NA | ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "2", "3", "5", "A", "B", "C", "E", "U", "V", "W", "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT025-0002 |
| 1678 | COT026 | ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT026-0001 |
| 1679 | COT026 | ADJUSTMENT-REASON-CODE | Not Applicable | NA | If there is no adjustment to a claim, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT026-0002 |
| 1680 | COT027 | DIAGNOSIS-CODE-1 | Not Applicable | NA | CLAIMOT: Code Specific ICD-9/10-CM code. There are many types of claims that aren’t expected to have diagnosis codes, such as transportation, DME, lab, etc. Do not add vague and unspecified diagnosis codes to those claims. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT027-0007 |
| 1681 | COT027 | DIAGNOSIS-CODE-1 | DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-2: Primary and Second ICD-9/10-CM code found on the claim. | Required | Code valid ICD-9/10‑CM codes without a decimal point. For example: 210.5 is coded as "2105". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html" | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT027-0001 |
| 1682 | COT027 | DIAGNOSIS-CODE-1 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT027-0002 |
| 1683 | COT027 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT027-0003 |
| 1684 | COT027 | DIAGNOSIS-CODE-1 | Not Applicable | NA | The primary diagnosis code goes into DIAGNOSIS-CODE-1 | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT027-0004 |
| 1685 | COT027 | DIAGNOSIS-CODE-1 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT027-0005 |
| 1686 | COT027 | DIAGNOSIS-CODE-1 | Not Applicable | NA | Enter invalid codes exactly as they appear in the State system. Do not 8-fill or 9-fill these items | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT027-0006 |
| 1687 | COT028 | DIAGNOSIS-CODE-FLAG-1 | CLAIMIP, CLAIMLT, CLAIMOT: A flag that identifies the coding system used for the DIAGNOSIS CODE 1 - 12 CLAIMIP, CLAIMOT, CLAIMOT: DIAGNOSIS-CODE-FLAG-1 through DIAGNOSIS-CODE-FLAG-2: Code flag for the Primary and Second ICD-9/10-CM code found on the claim. |
Required | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT028-0001 |
| 1688 | COT028 | DIAGNOSIS-CODE-FLAG-1 | Not Applicable | NA | For implementation date edits, Beginning Date of Service will be used for OT claims, and Ending Date of Service will be used for IP and LT claims. This is to be in alignment with the Medicare requirements. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT028-0002 |
| 1689 | COT028 | DIAGNOSIS-CODE-FLAG-1 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT028-0004 |
| 1690 | COT029 | DIAGNOSIS-POA-FLAG-1 | A code to identify conditions that are present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
NA | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT029-0001 |
| 1691 | COT029 | DIAGNOSIS-POA-FLAG-1 | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). The POA (present on admission) flag is only applicable on inpatient claims/encounters. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT029-0002 |
| 1692 | COT029 | DIAGNOSIS-POA-FLAG-1 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT029-0003 |
| 1693 | COT030 | DIAGNOSIS-CODE-2 | DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-2: Primary and Second ICD-9/10-CM code found on the claim | Conditional | Code valid ICD-9/10‑CM codes without a decimal point. For example: 210.5 is coded as "2105". | http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD10.html | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT030-0001 |
| 1694 | COT030 | DIAGNOSIS-CODE-2 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT030-0002 |
| 1695 | COT030 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Include all digits where applicable. ICD-9 codes are up to 5 positions long. ICD-10 codes are up to 7 positions long. Both ICD-9-CM and ICD-10-CM have a minimum length of 3 positions. Embedded blanks are not allowed | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT030-0003 |
| 1696 | COT030 | DIAGNOSIS-CODE-2 | Not Applicable | NA | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT030-0004 |
| 1697 | COT030 | DIAGNOSIS-CODE-2 | Not Applicable | NA | CLAIMOT: Code Specific ICD-9/10-CM code. There are many types of claims that aren’t expected to have diagnosis codes, such as transportation, DME, lab, etc. Do not add vague and unspecified diagnosis codes to those claims. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT030-0006 |
| 1698 | COT030 | DIAGNOSIS-CODE-2 | Not Applicable | NA | Do not report duplicate diagnosis codes across DIAGNOSIS-CODE data elements 1 -2. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT030-0007 |
| 1699 | COT031 | DIAGNOSIS-CODE-FLAG-2 | CLAIMIP, CLAIMOT, CLAIMOT: A flag that identifies the coding system used for the DIAGNOSIS CODE 1 - 12 CLAIMIP, CLAIMOT, CLAIMOT: DIAGNOSIS-CODE-FLAG-1 through DIAGNOSIS-CODE-FLAG-2: Code flag for the Primary and Second ICD-9/10-CM code found on the claim. |
Conditional | If the diagnosis code is blank-filled, then the corresponding diagnosis code flag should also be blank-filled. Any diagnosis code that IS NOT blank MUST have a valid diagnosis code flag. | 1 ICD-9 2 ICD-10 |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT031-0001 |
| 1700 | COT031 | DIAGNOSIS-CODE-FLAG-2 | Not Applicable | NA | For implementation date edits, Beginning Date of Service will be used for OT claims, and Ending Date of Service will be used for IP and LT claims. This is to be in alignment with the Medicare requirements. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT031-0002 |
| 1701 | COT031 | DIAGNOSIS-CODE-FLAG-2 | Not Applicable | NA | All UNUSED diagnosis code flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT031-0004 |
| 1702 | COT032 | DIAGNOSIS-POA-FLAG-2 | A code to identify conditions that are present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. |
NA | NOTE: The code “1” is no longer valid on claims submitted under the version 5010 format, effective January 1, 2011. The POA field will instead be left blank for codes exempt from POA reporting. See http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R756OTN.pdf for a listing of exempt diagnoses. | 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. |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT032-0001 |
| 1703 | COT032 | DIAGNOSIS-POA-FLAG-2 | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). The POA (present on admission) flag is only applicable on inpatient claims/encounters. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT032-0002 |
| 1704 | COT032 | DIAGNOSIS-POA-FLAG-2 | Not Applicable | NA | All UNUSED diagnosis code POA flag fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT032-0003 |
| 1705 | COT033 | BEGINNING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0001 |
| 1706 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0002 |
| 1707 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before or be the same as the end of time period | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0003 |
| 1708 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as Ending Date of Service | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0004 |
| 1709 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as adjudication date. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0005 |
| 1710 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0006 |
| 1711 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before the DATE-OF-BIRTH when the person is eligible as an unborn CHIP child or beginning date of service must occur on or after the DATE-OF-BIRTH when the person is eligible through Medicaid or is eligible as a non-unborn CHIP child . | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0007 |
| 1712 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A Medicaid claim record for an eligible individual should not have a Beginning Date of Service after the eligible individual's Medicaid enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0008 |
| 1713 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A CHIP claim record for an individual eligible for Separate CHIP cannot have a Beginning Date of Service after the eligible individual's CHIP enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0009 |
| 1714 | COT033 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT033-0010 |
| 1715 | COT034 | ENDING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0001 |
| 1716 | COT034 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0002 |
| 1717 | COT034 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must occur after or be the same as the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0003 |
| 1718 | COT034 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0004 |
| 1719 | COT034 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death, when a DATE-OF-DEATH is not unknown or not applicable. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0005 |
| 1720 | COT034 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or after DATE-OF-BIRTH | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0006 |
| 1721 | COT034 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as End of Time Period. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0007 |
| 1722 | COT034 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT034-0008 |
| 1723 | COT035 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT035-0001 |
| 1724 | COT035 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT035-0002 |
| 1725 | COT035 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT035-0003 |
| 1726 | COT035 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT035-0004 |
| 1727 | COT035 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT035-0005 |
| 1728 | COT035 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record when the eligible is not a CHIP unborn child. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT035-0006 |
| 1729 | COT035 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT035-0007 |
| 1730 | COT036 | MEDICAID-PAID-DATE | The date Medicaid paid on this claim or adjustment. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT036-0001 |
| 1731 | COT036 | MEDICAID-PAID-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT036-0002 |
| 1732 | COT037 | TYPE-OF-CLAIM | A code indicating what kind of payment is covered in this claim | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT037-0001 |
| 1733 | COT037 | TYPE-OF-CLAIM | Not Applicable | NA | States should only submit CHIP claims for CHIP eligibles | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT037-0002 |
| 1734 | COT037 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the basis of eligibility. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT037-0003 |
| 1735 | COT037 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the maintenance assistance status. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT037-0004 |
| 1736 | COT037 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the restricted benefits code. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT037-0005 |
| 1737 | COT037 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the TANF code. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT037-0006 |
| 1738 | COT037 | TYPE-OF-CLAIM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT037-0007 |
| 1739 | COT038 | TYPE-OF-BILL | A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.) | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT038-0001 |
| 1740 | COT039 | CLAIM-STATUS | The health care claim status codes convey the status of an entire claim. |
Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT039-0001 |
| 1741 | COT039 | CLAIM-STATUS | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1742 | COT040 | CLAIM-STATUS-CATEGORY | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.), which is then further detailed in the companion data element CLAIM-STATUS. | Required | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT040-0001 |
| 1743 | COT040 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All denied claims should have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1744 | COT040 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1745 | COT041 | SOURCE-LOCATION | The field denotes the claim payment system from which the claim was adjudicated. | Required | Value must be equal to a valid value. | 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) |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT041-0001 |
| 1746 | COT042 | CHECK-NUM | The check or EFT number | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT042-0001 |
| 1747 | COT042 | CHECK-NUM | Not Applicable | NA | If there is a valid check date there should also be a valid check number. | Date format is CCYYMMDD (National Data Standard). | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT042-0002 |
| 1748 | COT043 | CHECK-EFF-DATE | Date the check is issued to the payee, or if Electronic Funds Transfer (EFT), the date the transfer is made. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1749 | COT043 | CHECK-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1750 | COT043 | CHECK-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT043-0002 |
| 1751 | COT043 | CHECK-EFF-DATE | Not Applicable | NA | Could be the same as Remittance Date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT043-0003 |
| 1752 | COT043 | CHECK-EFF-DATE | Not Applicable | NA | If there is a valid check number, there should also be a valid check date. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT043-0004 |
| 1753 | COT044 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT044-0001 |
| 1754 | COT045 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT045-0001 |
| 1755 | COT046 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT046-0001 |
| 1756 | COT047 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT047-0001 |
| 1757 | COT048 | TOT-BILLED-AMT | The total amount billed for this claim at the claim header level as submitted by the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT048-0001 |
| 1758 | COT048 | TOT-BILLED-AMT | Not Applicable | NA | The total amount should be the sum of each of the billed amounts submitted at the claim detail level. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT048-0002 |
| 1759 | COT048 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000". | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT048-0003 |
| 1760 | COT048 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed the managed care plan. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT048-0004 |
| 1761 | COT049 | TOT-ALLOWED-AMT | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT049-0001 |
| 1762 | COT049 | TOT-ALLOWED-AMT | Not Applicable | NA | The sum of the allowed amounts at the detailed levels must equal TOT-ALLOWED-AMT | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT049-0002 |
| 1763 | COT050 | TOT-MEDICAID-PAID-AMT | The total amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Required | If TYPE-OF-CLAIM = 1 or A (fee-for-service claim) this field should be populated with the amount that the Medicaid agency paid to the provider. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT050-0001 |
| 1764 | COT050 | TOT-MEDICAID-PAID-AMT | Not Applicable | NA | If TYPE‐OF‐CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT050-0002 |
| 1765 | COT051 | TOT-COPAY-AMT | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT051-0001 |
| 1766 | COT052 | TOT-MEDICARE-DEDUCTIBLE-AMT | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary’s Medicare deductible. |
Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT052-0001 |
| 1767 | COT052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code MEDICARE-COMB-DED-IND with a "1", and code space in TOT-MEDICARE-COINS-AMT. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1768 | COT052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | The total Medicare deductible amount must be less than or equal the total billed amount. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT052-0002 |
| 1769 | COT053 | TOT-MEDICARE-COINS-AMT | The amount paid by Medicaid/CHIP, on this claim, toward the recipient's Medicare coinsurance at the claim detail level. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT053-0001 |
| 1770 | COT053 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | Value must be less than TOT-BILLED-AMT. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT053-0003 |
| 1771 | COT053 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code MEDICARE-COMB-DED-IND with a "1", and code space in TOT-MEDICARE-COINS-AMT. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT053-0005 |
| 1772 | COT054 | TOT-TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT054-0001 |
| 1773 | COT054 | TOT-TPL-AMT | Not Applicable | NA | The TOT-TPL-AMT should be =< TOT-BILLED-AMT - (minus) (TOT-MEDICARE-COINS-AMT + (plus) TOT-MEDICARE-DEDUCTIBLE-AMT). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT054-0002 |
| 1774 | COT056 | TOT-OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT056-0001 |
| 1775 | COT057 | OTHER-INSURANCE-IND | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT057-0001 |
| 1776 | COT058 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT058-0001 |
| 1777 | COT059 | SERVICE-TRACKING-TYPE | A code to categorize service tracking claims. A “service tracking claim” is used to report lump sum payments that cannot be attributed to a single enrollee. (Note: Use an encounter record to report services provided under a capitated payment arrangement.) | Conditional | Value must be equal to a valid value. | 00 Not a Service Tracking Claim 01 Drug Rebate 02 DSH Payment 03 Lump Sum Payment 04 Cost Settlement 05 Supplemental 06 Other |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT059-0001 |
| 1778 | COT059 | SERVICE-TRACKING-TYPE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT059-0002 |
| 1779 | COT059 | SERVICE-TRACKING-TYPE | Not Applicable | Conditional | This field is required if TYPE-OF-CLAIM equals a service tracking claim (Valid values for service tracking claims include 4, D, X) | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1780 | COT060 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Required on service tracking records, TYPE-OF-CLAIM equals 4, D, X) | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT060-0002 |
| 1781 | COT060 | SERVICE-TRACKING-PAYMENT-AMT | On service tracking claims, the lump sum amount paid to the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT060-0001 |
| 1782 | COT060 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Amount paid for services received by an individual patient, when the state accepts a lump sum form a provider that covered similar services delivered to more than one patient, such as a group screening for EPSDT | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT060-0003 |
| 1783 | COT060 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | For service tracking payments, ensure that the TOT-MEDICAID-PAID-AMOUNT is 0 filled and provide payment amount in SERVICE-TRACKING-PAYMENT-AMT only. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT060-0004 |
| 1784 | COT060 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | If there is a service tracking type, then there must also be a service tracking payment amount. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT060-0005 |
| 1785 | COT060 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | If SERVICE-TRACKING-TYPE <> "00" or "99", then SERVICE-TRACKING-PAYMENT-AMT must BE<> 000000000000. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT060-0006 |
| 1786 | COT061 | FIXED-PAYMENT-IND | This code indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management (PCCM) programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined “medical record” associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Conditional | Value must be equal to a valid value. | 0 Not Fixed Payment 1 FFS Fixed Payment |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT061-0001 |
| 1787 | COT062 | FUNDING-CODE | A code to indicate the source of non-federal share funds. | Required | Value must be equal to a valid value. | 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 |
10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT062-0001 |
| 1788 | COT063 | FUNDING-SOURCE-NONFEDERAL-SHARE | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. | Required | Value must be equal to a valid value. When states have multiple sources of FUNDING-SOURCE-NONFEDERAL-SHARE, States are to report the portion which represents the largest proportion as the 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 |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT063-0001 |
| 1789 | COT064 | MEDICARE-COMB-DED-IND | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. | Conditional | Value must be equal to a valid value. | 0 Amount not combined with coinsurance amount 1 Amount combined with coinsurance amount |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT064-0001 |
| 1790 | COT064 | MEDICARE-COMB-DED-IND | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any combined deductible amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT064-0003 |
| 1791 | COT065 | PROGRAM-TYPE | Code indicating special Medicaid program under which the service was provided. Refer to Appendix E for information on the various program types. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT065-0001 |
| 1792 | COT065 | PROGRAM-TYPE | Not Applicable | NA | Value for 1915 (c) waiver must correspond to the values for 1915(c) waiver in the Waiver Type. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT065-0002 |
| 1793 | COT065 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=Community First Choice (11) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 01 for the same time period. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT065-0003 |
| 1794 | COT065 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=1915(i) (value=13) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 02 for the same time period. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT065-0004 |
| 1795 | COT066 | PLAN-ID-NUMBER | A unique number, assigned by the state, which represents the health plan under which the non-fee-for-service encounter was provided including through the state plan and a waiver. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT066-0001 |
| 1796 | COT066 | PLAN-ID-NUMBER | Not Applicable | NA | Use the number as it is carried in the state’s system. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT066-0002 |
| 1797 | COT066 | PLAN-ID-NUMBER | Not Applicable | NA | If TYPE-OF-CLAIM<>3, C, W (Encounter Record) and TYPE-OF-SERVICE<> 119, 120, 121, 122 (Capitation payments), leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT066-0003 |
| 1798 | COT066 | PLAN-ID-NUMBER | Not Applicable | NA | The BILLING-PROV-NUM must equal this data element if the TYPE-OF-SERVICE=119, 122. See CMS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management Reporting" |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT066-0005 |
| 1799 | COT066 | PLAN-ID-NUMBER | Not Applicable | NA | The managed care ID on the individual's eligible record must match that which is included on any claims records (TYPE-OF-CLAIM= 3, C, W) for the eligible individual. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT066-0006 |
| 1800 | COT066 | PLAN-ID-NUMBER | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File" | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT066-0007 |
| 1801 | COT066 | PLAN-ID-NUMBER | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Dual-Eligible Code" | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT066-0008 |
| 1802 | COT067 | NATIONAL-HEALTH-CARE-ENTITY-ID | The national identifier of the health care entity (controlling health plan, subhealth plan, or other entity) at the most granular sub-health plan level of the Medicaid or CHIP health plan in which an individual is enrolled. See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT067-0001 |
| 1803 | COT067 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT067-0002 |
| 1804 | COT067 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | This field is required for all managed care claims and encounters with dates of service on or after the mandated dates above | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT067-0003 |
| 1805 | COT067 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | NATIONAL-HEALTH-CARE-ENTITY-IDs on managed care claims and encounters must match NATIONAL-HEALTH-CARE-ENTITY-IDs on file for the individual in the eligibility subject area or the TPL subject area. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT067-0004 |
| 1806 | COT068 | PAYMENT-LEVEL-IND | The field denotes whether the claim payment is made at the header level or the detail level. | Required | Value must be equal to a valid value. | 1 Claim Header – Sum of Line Item payments 2 Claim Detail – Individual Line Item payments |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT068-0001 |
| 1807 | COT068 | PAYMENT-LEVEL-IND | Not Applicable | NA | Payment fields at either the claim header or line on encounter records should be left blank | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT068-0002 |
| 1808 | COT069 | MEDICARE-REIM-TYPE | This code indicates the type of Medicare Reimbursement. |
Conditional | Value must be equal to a valid value. | 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 |
11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT069-0001 |
| 1809 | COT069 | MEDICARE-REIM-TYPE | Not Applicable | NA | If this is a crossover Medicare claim (CROSSOVER-IND= 1), the claim must have a MEDICARE-REIM-TYPE. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT069-0002 |
| 1810 | COT070 | CLAIM-LINE-COUNT | The total number of lines on the claim. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT070-0001 |
| 1811 | COT070 | CLAIM-LINE-COUNT | Not Applicable | NA | If the number of claim lines is above the state-approved limit, the record will be split and the SPLIT-CLAIM-IND will equal 1. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT070-0002 |
| 1812 | COT070 | CLAIM-LINE-COUNT | Not Applicable | NA | The claim line count should equal the sum of the claim lines for this record. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT070-0003 |
| 1813 | COT072 | FORCED-CLAIM-IND | This code indicates if the claim was processed by forcing it through a manual override process. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT072-0001 |
| 1814 | COT073 | HEALTH-CARE-ACQUIRED-CONDITION-IND | This code indicates whether the individual included on the claim has a Health Care Acquired Condition. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT073-0001 |
| 1815 | COT073 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Not Applicable | NA | For additional coding information refer to the following site : https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT073-0002 |
| 1816 | COT074 | OCCURRENCE-CODE-01 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT074-0001 |
| 1817 | COT074 | OCCURRENCE-CODE-01 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT074-0002 |
| 1818 | COT074 | OCCURRENCE-CODE-01 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT074-0003 |
| 1819 | COT075 | OCCURRENCE-CODE-02 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT075-0001 |
| 1820 | COT075 | OCCURRENCE-CODE-02 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT075-0002 |
| 1821 | COT075 | OCCURRENCE-CODE-02 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT075-0003 |
| 1822 | COT076 | OCCURRENCE-CODE-03 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT076-0001 |
| 1823 | COT076 | OCCURRENCE-CODE-03 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT076-0002 |
| 1824 | COT076 | OCCURRENCE-CODE-03 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT076-0003 |
| 1825 | COT077 | OCCURRENCE-CODE-04 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT077-0001 |
| 1826 | COT077 | OCCURRENCE-CODE-04 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT077-0002 |
| 1827 | COT077 | OCCURRENCE-CODE-04 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT077-0003 |
| 1828 | COT078 | OCCURRENCE-CODE-05 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT078-0001 |
| 1829 | COT078 | OCCURRENCE-CODE-05 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT078-0002 |
| 1830 | COT078 | OCCURRENCE-CODE-05 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT078-0003 |
| 1831 | COT079 | OCCURRENCE-CODE-06 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT079-0001 |
| 1832 | COT079 | OCCURRENCE-CODE-06 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT079-0002 |
| 1833 | COT079 | OCCURRENCE-CODE-06 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT079-0003 |
| 1834 | COT080 | OCCURRENCE-CODE-07 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT080-0001 |
| 1835 | COT080 | OCCURRENCE-CODE-07 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT080-0002 |
| 1836 | COT080 | OCCURRENCE-CODE-07 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT080-0003 |
| 1837 | COT081 | OCCURRENCE-CODE-08 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT081-0001 |
| 1838 | COT081 | OCCURRENCE-CODE-08 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT081-0002 |
| 1839 | COT081 | OCCURRENCE-CODE-08 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT081-0003 |
| 1840 | COT082 | OCCURRENCE-CODE-09 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT082-0001 |
| 1841 | COT082 | OCCURRENCE-CODE-09 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT082-0002 |
| 1842 | COT082 | OCCURRENCE-CODE-09 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT082-0003 |
| 1843 | COT083 | OCCURRENCE-CODE-10 | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT083-0001 |
| 1844 | COT083 | OCCURRENCE-CODE-10 | Not Applicable | NA | Required if reported on the claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT083-0002 |
| 1845 | COT083 | OCCURRENCE-CODE-10 | Not Applicable | NA | All UNUSED occurrence code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT083-0003 |
| 1846 | COT084 | OCCURRENCE-CODE-EFF-DATE-01 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1847 | COT084 | OCCURRENCE-CODE-EFF-DATE-01 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT084-0001 |
| 1848 | COT084 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT084-0002 |
| 1849 | COT084 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT084-0003 |
| 1850 | COT084 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT084-0004 |
| 1851 | COT084 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT084-0005 |
| 1852 | COT084 | OCCURRENCE-CODE-EFF-DATE-01 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT084-0006 |
| 1853 | COT085 | OCCURRENCE-CODE-EFF-DATE-02 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1854 | COT085 | OCCURRENCE-CODE-EFF-DATE-02 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT085-0001 |
| 1855 | COT085 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT085-0002 |
| 1856 | COT085 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT085-0003 |
| 1857 | COT085 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT085-0004 |
| 1858 | COT085 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT085-0005 |
| 1859 | COT085 | OCCURRENCE-CODE-EFF-DATE-02 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT085-0006 |
| 1860 | COT086 | OCCURRENCE-CODE-EFF-DATE-03 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1861 | COT086 | OCCURRENCE-CODE-EFF-DATE-03 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT086-0001 |
| 1862 | COT086 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT086-0002 |
| 1863 | COT086 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT086-0003 |
| 1864 | COT086 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT086-0004 |
| 1865 | COT086 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT086-0005 |
| 1866 | COT086 | OCCURRENCE-CODE-EFF-DATE-03 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT086-0006 |
| 1867 | COT087 | OCCURRENCE-CODE-EFF-DATE-04 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1868 | COT087 | OCCURRENCE-CODE-EFF-DATE-04 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT087-0001 |
| 1869 | COT087 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT087-0002 |
| 1870 | COT087 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT087-0003 |
| 1871 | COT087 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT087-0004 |
| 1872 | COT087 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT087-0005 |
| 1873 | COT087 | OCCURRENCE-CODE-EFF-DATE-04 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT087-0006 |
| 1874 | COT088 | OCCURRENCE-CODE-EFF-DATE-05 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1875 | COT088 | OCCURRENCE-CODE-EFF-DATE-05 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT088-0001 |
| 1876 | COT088 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT088-0002 |
| 1877 | COT088 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT088-0003 |
| 1878 | COT088 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT088-0004 |
| 1879 | COT088 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT088-0005 |
| 1880 | COT088 | OCCURRENCE-CODE-EFF-DATE-05 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT088-0006 |
| 1881 | COT089 | OCCURRENCE-CODE-EFF-DATE-06 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1882 | COT089 | OCCURRENCE-CODE-EFF-DATE-06 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT089-0001 |
| 1883 | COT089 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT089-0002 |
| 1884 | COT089 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT089-0003 |
| 1885 | COT089 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT089-0004 |
| 1886 | COT089 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT089-0005 |
| 1887 | COT089 | OCCURRENCE-CODE-EFF-DATE-06 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT089-0006 |
| 1888 | COT090 | OCCURRENCE-CODE-EFF-DATE-07 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1889 | COT090 | OCCURRENCE-CODE-EFF-DATE-07 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT090-0001 |
| 1890 | COT090 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT090-0002 |
| 1891 | COT090 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT090-0003 |
| 1892 | COT090 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT090-0004 |
| 1893 | COT090 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT090-0005 |
| 1894 | COT090 | OCCURRENCE-CODE-EFF-DATE-07 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT090-0006 |
| 1895 | COT091 | OCCURRENCE-CODE-EFF-DATE-08 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1896 | COT091 | OCCURRENCE-CODE-EFF-DATE-08 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT091-0001 |
| 1897 | COT091 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT091-0002 |
| 1898 | COT091 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT091-0003 |
| 1899 | COT091 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT091-0004 |
| 1900 | COT091 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT091-0005 |
| 1901 | COT091 | OCCURRENCE-CODE-EFF-DATE-08 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT091-0006 |
| 1902 | COT092 | OCCURRENCE-CODE-EFF-DATE-09 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1903 | COT092 | OCCURRENCE-CODE-EFF-DATE-09 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT092-0001 |
| 1904 | COT092 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT092-0002 |
| 1905 | COT092 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT092-0003 |
| 1906 | COT092 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT092-0004 |
| 1907 | COT092 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT092-0005 |
| 1908 | COT092 | OCCURRENCE-CODE-EFF-DATE-09 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT092-0006 |
| 1909 | COT093 | OCCURRENCE-CODE-EFF-DATE-10 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1910 | COT093 | OCCURRENCE-CODE-EFF-DATE-10 | The start date of the corresponding occurrence code or occurrence span codes. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT093-0001 |
| 1911 | COT093 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT093-0002 |
| 1912 | COT093 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT093-0003 |
| 1913 | COT093 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT093-0004 |
| 1914 | COT093 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | Value must be less than or equal to the corresponding OCCURRENCE-CODE-END-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT093-0005 |
| 1915 | COT093 | OCCURRENCE-CODE-EFF-DATE-10 | Not Applicable | NA | All UNUSED occurrence code effective date fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT093-0006 |
| 1916 | COT094 | OCCURRENCE-CODE-END-DATE-01 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT094-0001 |
| 1917 | COT094 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT094-0002 |
| 1918 | COT094 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT094-0003 |
| 1919 | COT094 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT094-0004 |
| 1920 | COT094 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT094-0005 |
| 1921 | COT094 | OCCURRENCE-CODE-END-DATE-01 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT094-0006 |
| 1922 | COT095 | OCCURRENCE-CODE-END-DATE-02 | A model of health care delivery organized to provide a defined set of services. | Conditional | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT095-0005 |
| 1923 | COT095 | OCCURRENCE-CODE-END-DATE-02 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT095-0001 |
| 1924 | COT095 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT095-0002 |
| 1925 | COT095 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT095-0003 |
| 1926 | COT095 | OCCURRENCE-CODE-END-DATE-02 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT095-0006 |
| 1927 | COT096 | OCCURRENCE-CODE-END-DATE-03 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT096-0001 |
| 1928 | COT096 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT096-0002 |
| 1929 | COT096 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT096-0003 |
| 1930 | COT096 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT096-0004 |
| 1931 | COT096 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT096-0005 |
| 1932 | COT096 | OCCURRENCE-CODE-END-DATE-03 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT096-0006 |
| 1933 | COT097 | OCCURRENCE-CODE-END-DATE-04 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT097-0001 |
| 1934 | COT097 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT097-0002 |
| 1935 | COT097 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT097-0003 |
| 1936 | COT097 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT097-0004 |
| 1937 | COT097 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT097-0005 |
| 1938 | COT097 | OCCURRENCE-CODE-END-DATE-04 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT097-0006 |
| 1939 | COT098 | OCCURRENCE-CODE-END-DATE-05 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT098-0001 |
| 1940 | COT098 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT098-0002 |
| 1941 | COT098 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT098-0003 |
| 1942 | COT098 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT098-0004 |
| 1943 | COT098 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT098-0005 |
| 1944 | COT098 | OCCURRENCE-CODE-END-DATE-05 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT098-0006 |
| 1945 | COT099 | OCCURRENCE-CODE-END-DATE-06 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT099-0001 |
| 1946 | COT099 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT099-0002 |
| 1947 | COT099 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT099-0003 |
| 1948 | COT099 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT099-0004 |
| 1949 | COT099 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT099-0005 |
| 1950 | COT099 | OCCURRENCE-CODE-END-DATE-06 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT099-0006 |
| 1951 | COT100 | OCCURRENCE-CODE-END-DATE-07 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT100-0001 |
| 1952 | COT100 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT100-0002 |
| 1953 | COT100 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT100-0003 |
| 1954 | COT100 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT100-0004 |
| 1955 | COT100 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT100-0005 |
| 1956 | COT100 | OCCURRENCE-CODE-END-DATE-07 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT100-0006 |
| 1957 | COT101 | OCCURRENCE-CODE-END-DATE-08 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT101-0001 |
| 1958 | COT101 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT101-0002 |
| 1959 | COT101 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT101-0003 |
| 1960 | COT101 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT101-0004 |
| 1961 | COT101 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT101-0005 |
| 1962 | COT101 | OCCURRENCE-CODE-END-DATE-08 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT101-0006 |
| 1963 | COT102 | OCCURRENCE-CODE-END-DATE-09 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT102-0001 |
| 1964 | COT102 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT102-0002 |
| 1965 | COT102 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT102-0003 |
| 1966 | COT102 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT102-0004 |
| 1967 | COT102 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT102-0005 |
| 1968 | COT102 | OCCURRENCE-CODE-END-DATE-09 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT102-0006 |
| 1969 | COT103 | OCCURRENCE-CODE-END-DATE-10 | The last date that the corresponding occurrence code or occurrence span code was applicable. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT103-0001 |
| 1970 | COT103 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT103-0002 |
| 1971 | COT103 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | If the occurrence date span is a single day, then populate the OCCURRENCE-CODE-EFF-DATE and OCCURRENCE-CODE-END-DATE fields with the same date | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT103-0003 |
| 1972 | COT103 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Required when the corresponding OCCURRENCE-CODE field is populated | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT103-0004 |
| 1973 | COT103 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must correspond to the OCCURRENCE-CODE value | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT103-0005 |
| 1974 | COT103 | OCCURRENCE-CODE-END-DATE-10 | Not Applicable | NA | Value must be greater than or equal to the corresponding OCCURRENCE-CODE-EFF-DATE field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT103-0006 |
| 1975 | COT104 | PATIENT-CONTROL-NUM | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client’s episode of service within the provider’s system to facilitate retrieval of individual financial and clinical records and posting of payment. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT104-0001 |
| 1976 | COT105 | ELIGIBLE-LAST-NAME | The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT105-0001 |
| 1977 | COT105 | ELIGIBLE-LAST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT105-0002 |
| 1978 | COT106 | ELIGIBLE-FIRST-NAME | The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT106-0001 |
| 1979 | COT106 | ELIGIBLE-FIRST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT106-0002 |
| 1980 | COT107 | ELIGIBLE-MIDDLE-INIT | The middle initial of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT107-0001 |
| 1981 | COT107 | ELIGIBLE-MIDDLE-INIT | Not Applicable | NA | Leave blank if not available When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. |
Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT107-0002 |
| 1982 | COT108 | DATE-OF-BIRTH | Date of birth of the individual to whom the services were provided. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT108-0001 |
| 1983 | COT108 | DATE-OF-BIRTH | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT108-0002 |
| 1984 | COT108 | DATE-OF-BIRTH | Not Applicable | NA | The numeric form for days and months from 1 to 9 must have a zero as the first digit. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT108-0003 |
| 1985 | COT108 | DATE-OF-BIRTH | Not Applicable | NA | A patient's age should not be greater than 112 years. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT108-0005 |
| 1986 | COT109 | HEALTH-HOME-PROV-IND | This code indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT109-0001 |
| 1987 | COT109 | HEALTH-HOME-PROV-IND | Not Applicable | NA | If a state has not yet begun collecting this information, HEALTH-HOME-PROVIDER-IND, this field should be defaulted to the value “8.” | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT109-0002 |
| 1988 | COT109 | HEALTH-HOME-PROV-IND | Not Applicable | NA | If there is a HEALTH-HOME-ENTITY-NAME then HEALTH-HOME-PROV-IND must indicate yes. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT109-0003 |
| 1989 | COT109 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States should not submit claim records for an eligible individual that indicate the claim was submitted by a provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT109-0004 |
| 1990 | COT109 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT109-0005 |
| 1991 | COT110 | WAIVER-TYPE | Code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Conditional | Enter the WAIVER-TYPE assigned | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT110-0001 |
| 1992 | COT110 | WAIVER-TYPE | Not Applicable | NA | Value must correspond to associated WAIVER-ID | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT110-0002 |
| 1993 | COT110 | WAIVER-TYPE | Not Applicable | NA | An ineligible individual should not have a category for federal reimbursement for Medicaid or CHIP (CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT <> 01,02) | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT110-0003 |
| 1994 | COT111 | WAIVER-ID | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. The categories of demonstration and waiver programs include: 1915(b)(1); 1915(b)(2); 1915(b)(3), and 1915(b)(4) managed care waivers; 1915(c) home and community based services waivers; combined 1915(b) and 1915(c) managed home and community based services waivers and 1115 demonstrations. | Conditional | Not Applicable | Valid values are supplied by the state. | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 1995 | COT111 | WAIVER-ID | Not Applicable | NA | Report the full federal waiver identifier. | Not Applicable | 11/9/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT111-0002 |
| 1996 | COT111 | WAIVER-ID | Not Applicable | NA | If the goods & services rendered do not fall under a waiver, leave this field blank. | Not Applicable | 11/9/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT111-0004 |
| 1997 | COT111 | WAIVER-ID | Not Applicable | NA | If there's a waiver type, there should be a corresponding waiver id. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT111-0005 |
| 1998 | COT112 | BILLING-PROV-NUM | A unique identification number assigned by the state to a provider or capitation plan. This should represent the entity billing for the service. | Required | If value is invalid, record it exactly as it appears in the state system. | Valid values are supplied by the state. | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT112-0001 |
| 1999 | COT112 | BILLING-PROV-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), this represents the entity billing (or reporting) to the managed care plan (See PLAN-ID-NUMBER for reporting capitation plan-ID). Capitation PLAN-ID-NUMBER should be used in this field only for capitation payments (TYPE-OF-SERVICE = 119, 120, 122). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT112-0002 |
| 2000 | COT112 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT112-0003 |
| 2001 | COT112 | BILLING-PROV-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT112-0004 |
| 2002 | COT112 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT112-0005 |
| 2003 | COT112 | BILLING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT112-0006 |
| 2004 | COT113 | BILLING-PROV-NPI-NUM | The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care. |
Conditional | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT113-0001 |
| 2005 | COT113 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT113-0002 |
| 2006 | COT113 | BILLING-PROV-NPI-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity billing (or reporting) to the managed care plan. For financial transactions (i.e., expenditure transactions or recoupments of previously made expenditures that do not flow through the usual claim adjudication/adjustment process or encounter record reporting process), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity to which the financial transaction was addressed, unless the transaction is a payment/recoupment made-to/received-from a managed care plan, in which case the BILLING-PROV-NPI-NUM should be left blank. For financial transactions with managed care plans, the plan's ID should be reported in the PLAN-ID-NUMBER field and the BILLING-PROV-NPI-NUM should be left blank. |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT113-0003 |
| 2007 | COT113 | BILLING-PROV-NPI-NUM | Not Applicable | NA | If legacy identifiers are available for providers, then report the legacy IDs in the Provider ID field and the NPI in this field. If only the legacy Provider ID is available, thenleave blank or space-fill the National Provider ID and enter the legacy IDs in the Provider ID fields. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT113-0004 |
| 2008 | COT113 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Billing Provider must be enrolled | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT113-0006 |
| 2009 | COT114 | BILLING-PROV-TAXONOMY | For CLAIMOT and CLAIMRX files, the taxonomy code for the provider billing for the service. | Conditional | Value must be in the set of valid values | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT114-0001 |
| 2010 | COT114 | BILLING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT114-0002 |
| 2011 | COT114 | BILLING-PROV-TAXONOMY | Not Applicable | NA | Leave blank or space-fill field for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122) | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT114-0003 |
| 2012 | COT115 | BILLING-PROV-TYPE | A code describing the type of entity billing for the service. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT115-0001 |
| 2013 | COT115 | BILLING-PROV-TYPE | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM= 3, C, W), this represents the entity billing (or reporting) to the Managed Care Plan (see PLAN-ID-NUMBER for reporting capitation plan-ID). Capitation PLAN-ID-NUMBER should be used in this field only for capitation payments (TYPE-OF-SERVICE=119, 120, 122). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT115-0002 |
| 2014 | COT115 | BILLING-PROV-TYPE | Not Applicable | NA | The state should use Taxonomy Crosswalk.pdf to crosswalk state codes to CMS codes | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT115-0003 |
| 2015 | COT116 | BILLING-PROV-SPECIALTY | This code describes the area of specialty for the billing provider. | Conditional | Must be in the set of valid values | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT116-0001 |
| 2016 | COT117 | REFERRING-PROV-NUM | A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual’s ID number, not a group identification number. | Conditional | If Value is invalid, record it exactly as it appears in the state system | Valid values are supplied by the state. | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT117-0001 |
| 2017 | COT117 | REFERRING-PROV-NUM | Not Applicable | NA | If the Referring Provider Number is not available, but the physician’s Drug Enforcement Agency (DEA) ID is on the state file, then the state should use the DEA ID for this data element. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT117-0002 |
| 2018 | COT117 | REFERRING-PROV-NUM | Not Applicable | NA | The value reported in REFERRING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT117-0003 |
| 2019 | COT117 | REFERRING-PROV-NUM | Not Applicable | NA | The value reported in REFERRING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT117-0004 |
| 2020 | COT117 | REFERRING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT117-0005 |
| 2021 | COT118 | REFERRING-PROV-NPI-NUM | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | Conditional | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT118-0001 |
| 2022 | COT118 | REFERRING-PROV-NPI-NUM | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT118-0002 |
| 2023 | COT118 | REFERRING-PROV-NPI-NUM | Not Applicable | NA | The field should be blank if the transaction is for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT118-0003 |
| 2024 | COT119 | REFERRING-PROV-TAXONOMY | For CLAIMOT files, the taxonomy code for the provider who referred the beneficiary for treatment. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT119-0001 |
| 2025 | COT119 | REFERRING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT119-0002 |
| 2026 | COT119 | REFERRING-PROV-TAXONOMY | Not Applicable | NA | Leave blank or space-fill field for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT119-0003 |
| 2027 | COT120 | REFERRING-PROV-TYPE | A code describing the type of provider (i.e. doctor) who referred the patient. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided |
NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT120-0001 |
| 2028 | COT121 | REFERRING-PROV-SPECIALTY | This code indicates the area of specialty of the referring provider. | NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT121-0001 |
| 2029 | COT122 | MEDICARE-HIC-NUM | Health Insurance Claim (HIC) Number as it appears on the patient’s Medicare card. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT122-0001 |
| 2030 | COT122 | MEDICARE-HIC-NUM | Not Applicable | NA | If this is a crossover Medicare claim, the Bene must have a MEDICARE-HIC-Num. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT122-0003 |
| 2031 | COT122 | MEDICARE-HIC-NUM | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's Medicare HIC Number does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT122-0004 |
| 2032 | COT122 | MEDICARE-HIC-NUM | Not Applicable | NA | Claims records for an eligible individual should not indicate a valid Medicare HIC number, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT122-0005 |
| 2033 | COT123 | PLACE-OF-SERVICE | A code indicating where the service was performed. CMS 1500 values are used for this data element. | Conditional | Value must be equal to a valid value. | http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT123-0001 |
| 2034 | COT123 | PLACE-OF-SERVICE | Not Applicable | NA | If there are new valid CMS 1500 PLACE-OF-SERVICE codes that are not listed in this dictionary, these codes may be used and will not trigger an error | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT123-0003 |
| 2035 | COT123 | PLACE-OF-SERVICE | Not Applicable | NA | Leave field blank for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT123-0004 |
| 2036 | COT125 | BMI | A key index for relating a person's body weight to their height. The body mass index (BMI) is a person's weight in kilograms (kg) divided by their height in meters (m) squared. | Optional | SI units: BMI = mass (kg) / (height(m))2 Imperial/US Customary units: BMI = mass (lb) * 703/ (height(in))2 BMI = mass (lb) * 4.88/ (height(ft))2 BMI = mass (st) * 9840/ (height(in))2 |
Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT125-0001 |
| 2037 | COT125 | BMI | Not Applicable | NA | CMS is relieving states of the responsibility to: (a) Provide these data. (b) Document a mitigation plan in the Source-to-Target-Mapping Matrix Addendum B whenever the data elements cannot be populated all of the time. However if a state determines that it can populate one or more of these fields and wishes to do so, they are encouraged to do so and will not incur any Addendum B mitigation plan documentation expectations. |
Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT125-0002 |
| 2038 | COT126 | REMITTANCE-NUM | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT126-0001 |
| 2039 | COT126 | REMITTANCE-NUM | Not Applicable | NA | Value must not be null | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT126-0002 |
| 2040 | COT126 | REMITTANCE-NUM | Not Applicable | NA | If there is a remittance date, then there must also be a remittance number. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT126-0003 |
| 2041 | COT127 | DAILY-RATE | The amount a policy will pay per day for a covered service. In some cases for OT claims this is referred to as a flat rate. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT127-0001 |
| 2042 | COT128 | BORDER-STATE-IND | This code indicates whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT128-0001 |
| 2043 | COT130 | BENEFICIARY-COINSURANCE-AMOUNT | The amount of money the beneficiary paid towards coinsurance. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT130-0001 |
| 2044 | COT130 | BENEFICIARY-COINSURANCE-AMOUNT | Not Applicable | NA | If no coinsurance is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT130-0002 |
| 2045 | COT131 | BENEFICIARY-COINSURANCE-DATE-PAID | The date the beneficiary paid the coinsurance amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT131-0001 |
| 2046 | COT131 | BENEFICIARY-COINSURANCE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT131-0002 |
| 2047 | COT131 | BENEFICIARY-COINSURANCE-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT131-0003 |
| 2048 | COT132 | BENEFICIARY-COPAYMENT-AMOUNT | The amount of money the beneficiary paid towards a copayment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT132-0001 |
| 2049 | COT132 | BENEFICIARY-COPAYMENT-AMOUNT | Not Applicable | NA | If no copayment is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT132-0002 |
| 2050 | COT133 | BENEFICIARY-COPAYMENT-DATE-PAID | The date the beneficiary paid the copayment amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT133-0001 |
| 2051 | COT133 | BENEFICIARY-COPAYMENT-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT133-0002 |
| 2052 | COT133 | BENEFICIARY-COPAYMENT-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT133-0003 |
| 2053 | COT134 | BENEFICIARY-DEDUCTIBLE-AMOUNT | The amount of money the beneficiary paid towards an annual deductible. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT134-0001 |
| 2054 | COT134 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Not Applicable | NA | If no deductible is applicable enter 0.00 | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT134-0002 |
| 2055 | COT135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | The date the beneficiary paid the deductible amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT135-0001 |
| 2056 | COT135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT135-0002 |
| 2057 | COT135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT135-0003 |
| 2058 | COT136 | CLAIM-DENIED-INDICATOR | An indicator to identify a claim that the state refused pay in its entirety. | Conditional | Value must be equal to a valid value. | 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. |
11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT136-0001 |
| 2059 | COT136 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | It is expected that states will submit all denied claims to CMS. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT136-0002 |
| 2060 | COT136 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All denied claims should have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT136-0003 |
| 2061 | COT136 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 2062 | COT137 | COPAY-WAIVED-IND | An indicator signifying that the copay was waived by the provider. | Conditional | Value must be equal to a valid value. | 0 Not Waived: The provider did not waive the beneficiary’s copayment 1 Waived: The provider waived the beneficiary’s copayment |
8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT137-0001 |
| 2063 | COT138 | HEALTH-HOME-ENTITY-NAME | A free-form text field to indicate the health home program that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A “Health Home Entity” can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities’ names are being used instead. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT138-0001 |
| 2064 | COT138 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's health home entity name does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT138-0002 |
| 2065 | COT140 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item. | Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT140-0001 |
| 2066 | COT141 | THIRD-PARTY-COINSURANCE-DATE-PAID | The date the third party paid the coinsurance amount. | Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT141-0001 |
| 2067 | COT141 | THIRD-PARTY-COINSURANCE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT141-0002 |
| 2068 | COT141 | THIRD-PARTY-COINSURANCE-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT141-0003 |
| 2069 | COT142 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | The amount the third party paid the copayment amount. | Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT142-0001 |
| 2070 | COT143 | THIRD-PARTY-COPAYMENT-DATE-PAID | The date the third party paid the copayment amount. | Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT143-0001 |
| 2071 | COT143 | THIRD-PARTY-COPAYMENT-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT143-0002 |
| 2072 | COT143 | THIRD-PARTY-COPAYMENT-DATE-PAID | Not Applicable | NA | If no coinsurance is applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT143-0003 |
| 2073 | COT144 | DATE-CAPITATED-AMOUNT-REQUESTED | The date that the managed care entity submitted the capitated payment bill to the state. | Conditional | Date format should be CCYYMMDD (National Data Standard) | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT144-0001 |
| 2074 | COT144 | DATE-CAPITATED-AMOUNT-REQUESTED | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT144-0002 |
| 2075 | COT145 | CAPITATED-PAYMENT-AMT-REQUESTED | The amount of the capitated payment bill submitted by the managed care entity to the state. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT145-0001 |
| 2076 | COT146 | HEALTH-HOME-PROVIDER-NPI | The National Provider ID (NPI) of the health home provider. | Conditional | The value must be a valid NPI | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT146-0001 |
| 2077 | COT146 | HEALTH-HOME-PROVIDER-NPI | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT146-0002 |
| 2078 | COT147 | MEDICARE-BENEFICIARY-IDENTIFIER | The individual’s Medicare Beneficiary Identifier (MBI) Identification Number. Note: MBI replaces the HICN with an entirely new Medicare Beneficiary Identifier (MBI) for purposes of provider billing, if applicable. CMS interfaces with non-payment exchange partners would remain HICN-based, while interfaces with payment partners would use the new MBI. |
NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT147-0001 |
| 2079 | COT147 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | If individual is NOT enrolled in Medicare, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT147-0002 |
| 2080 | COT147 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) until such time as the Medicare Beneficiary Identifier is implemented (no target date has been established). | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT147-0003 |
| 2081 | COT148 | UNDER-DIRECTION-OF-PROV-NPI | The National Provider ID (NPI) of the provider who directed the care of a patient that another provider administered. | NA | Not Applicable | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable |
| 2082 | COT148 | UNDER-DIRECTION-OF-PROV-NPI | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). This data element is a duplicate of the “UNDER-SUPERVISION-OF-PROV-NPI” field and as such do not need to be populated. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT148-0002 |
| 2083 | COT149 | UNDER-DIRECTION-OF-PROV-TAXONOMY | The Provider Taxonomy of the provider who directed the care of a patient that another provider administered. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT149-0001 |
| 2084 | COT149 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT149-0002 |
| 2085 | COT149 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT149-0003 |
| 2086 | COT149 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). This data element is a duplicate of the “UNDER-SUPERVISION-OF-PROV-TAXONOMY” field and as such do not need to be populated. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT149-0004 |
| 2087 | COT150 | UNDER-SUPERVISION-OF-PROV-NPI | The National Provider ID (NPI) of the provider who supervised another provider. | Conditional | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT150-0001 |
| 2088 | COT150 | UNDER-SUPERVISION-OF-PROV-NPI | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT150-0002 |
| 2089 | COT151 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | The Provider Taxonomy of the provider who supervised another provider | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT151-0001 |
| 2090 | COT151 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT151-0002 |
| 2091 | COT151 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT151-0003 |
| 2092 | COT152 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT152-0001 |
| 2093 | COT152 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT152-0002 |
| 2094 | COT153 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT153-0001 |
| 2095 | COT154 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002. | Required | Value must be equal to a valid value. | COT00003 | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT154-0001 |
| 2096 | COT154 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT154-0002 |
| 2097 | COT155 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT155-0001 |
| 2098 | COT155 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT155-0002 |
| 2099 | COT155 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT155-0003 |
| 2100 | COT155 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT155-0004 |
| 2101 | COT156 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT156-0001 |
| 2102 | COT156 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT156-0002 |
| 2103 | COT156 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT156-0004 |
| 2104 | COT157 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT157-0001 |
| 2105 | COT157 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the state ID numbers must be supplied to CMS | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT157-0002 |
| 2106 | COT157 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For TYPE-OF-CLAIM = 4 or D (lump sum adjustments), this field must begin with an ‘&’. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT157-0003 |
| 2107 | COT157 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT157-0004 |
| 2108 | COT157 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT157-0005 |
| 2109 | COT158 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT158-0001 |
| 2110 | COT158 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT158-0002 |
| 2111 | COT158 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT158-0003 |
| 2112 | COT158 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable |
| 2113 | COT159 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT159-0001 |
| 2114 | COT159 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT159-0002 |
| 2115 | COT159 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT159-0003 |
| 2116 | COT160 | LINE-NUM-ORIG | A unique number to identify the transaction line number that is being reported on the original claim. | Required | Record the value exactly as it appears in the State system. Do not pad. This field should also be completed on adjustment claims to reflect the LINE-NUMBER of the INTERNAL-CONTROL-NUMBER on the claim that is being adjusted | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT160-0001 |
| 2117 | COT161 | LINE-NUM-ADJ | A unique number to identify the transaction line number that identifies the line number on the adjustment ICN. | Conditional | Record the value exactly as it appears in the state system. Do not pad. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT161-0001 |
| 2118 | COT161 | LINE-NUM-ADJ | Not Applicable | NA | This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number. |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT161-0002 |
| 2119 | COT162 | LINE-ADJUSTMENT-IND | Code indicating type of adjustment record claim/encounter represents at claim detail level. | Conditional | Value must be equal to a valid value. | 0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT162-0001 |
| 2120 | COT162 | LINE-ADJUSTMENT-IND | Not Applicable | NA | If there is a line adjustment number, then there must be a line-adjustment indicator. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT162-0002 |
| 2121 | COT162 | LINE-ADJUSTMENT-IND | Not Applicable | NA | If there is a line adjustment reason, then there must be a line adjustment indicator. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT162-0003 |
| 2122 | COT162 | LINE-ADJUSTMENT-IND | Not Applicable | NA | Value must be equal to a valid value. ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "2", "3", "5", "A", "B", "C", "E", "U", "V", "W", or "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT162-0004 |
| 2123 | COT163 | LINE-ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT163-0001 |
| 2124 | COT163 | LINE-ADJUSTMENT-REASON-CODE | Not Applicable | NA | If there is no adjustment to a line, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE) | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT163-0002 |
| 2125 | COT164 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to state’s claim adjudication system. | Conditional | Value must not be null | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT164-0001 |
| 2126 | COT165 | CLAIM-LINE-STATUS | The claim line status codes identify the status of a specific detail claim line rather than the entire claim. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT165-0001 |
| 2127 | COT166 | BEGINNING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days or periods of care extending over two or more days, the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0001 |
| 2128 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0002 |
| 2129 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before or be the same as the ending date of service. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0003 |
| 2130 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as adjudication date. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0004 |
| 2131 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0005 |
| 2132 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | The beginning date of service must occur before the DATE-OF-BIRTH when the person is eligible as an unborn CHIP child or beginning date of service must occur on or after the DATE-OF-BIRTH when the person is eligible through Medicaid or is eligible as a non-unborn CHIP child . | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0006 |
| 2133 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A Medicaid claim record for an eligible individual, if applicable, should not have a Beginning Date of Service after the eligible individual's Medicaid enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0007 |
| 2134 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | A CHIP claim record for an individual eligible for Separate CHIP cannot have a Beginning Date of Service after the eligible individual's CHIP enrollment has ended. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0008 |
| 2135 | COT166 | BEGINNING-DATE-OF-SERVICE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT166-0009 |
| 2136 | COT167 | ENDING-DATE-OF-SERVICE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0001 |
| 2137 | COT167 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0002 |
| 2138 | COT167 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must occur after or be the same as the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0003 |
| 2139 | COT167 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0004 |
| 2140 | COT167 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur on or before Date of Death, when a DATE-OF-DEATH is not unknown or not applicable. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0005 |
| 2141 | COT167 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | ENDING-DATE-OF-SERVICE must be on or after DATE-OF-BIRTH | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0006 |
| 2142 | COT167 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | Date must occur before or be the same as End of Time Period. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0007 |
| 2143 | COT167 | ENDING-DATE-OF-SERVICE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Health Insurance Premium payments in the T‐MSIS OT File". | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT167-0008 |
| 2144 | COT168 | REVENUE-CODE | A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing Manual). | Conditional | Only valid codes as defined by the “National Uniform Billing Committee” should be used. | Revenue code is a data set that health care providers or insurers usually pay for to use. These values will change annually. | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT168-0001 |
| 2145 | COT168 | REVENUE-CODE | Not Applicable | NA | Enter all UB-04 Revenue Codes listed on the claim | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT168-0002 |
| 2146 | COT168 | REVENUE-CODE | Not Applicable | NA | Value must be a valid code | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT168-0003 |
| 2147 | COT168 | REVENUE-CODE | Not Applicable | NA | If value invalid, record it exactly as it appears in the state system | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT168-0004 |
| 2148 | COT169 | PROCEDURE-CODE | A field to capture the CPT or HCPCS code that describes a service or good rendered by the provider to an enrollee on the specified date of service. | Required | Value must be a valid code. If PROCDURE-CODE-FLAG-1 = {10 through 87, state-specific coding systems} valid codes must be supplied by the State. For national coding systems, code should conform to the nationally recognized formats: CPT (PROC-CD-FLAG-1=01): Positions 1-5 should be numeric and position 6-7 must be blank. HCPCS (PROC-CD-FLAG-1=06): Position 1 must be an alpha character (“A”-“Z”) and position 6-7 must be blank.. Value can include both National and Local (Regional) codes. For National codes (position 1=“A”-“V”) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or “WW234"). |
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. |
10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT169-0001 |
| 2149 | COT169 | PROCEDURE-CODE | Not Applicable | NA | If no PROCEDURE-CODE was performed, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT169-0002 |
| 2150 | COT169 | PROCEDURE-CODE | Not Applicable | NA | ICD-9/10-CM codes are the HIPAA standard for procedure codes on inpatient claims. When ICD-9/10-CM coding is used, the PROCDURE-CODE-FLAG-1=02/07) Positions 1-2 must be numeric, positions 3-4 must be numeric or blank, positions 5-7 must be blank. When ICD-10-PCS coding is used starting 10/1/2014, the PROCDURE-CODE-FLAG-1=07. Positions 1-7 must be alpha or numeric. Position 8 must be blank. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT169-0003 |
| 2151 | COT169 | PROCEDURE-CODE | Not Applicable | NA | Note: An eighth character is provided for future expansion of this field | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT169-0004 |
| 2152 | COT169 | PROCEDURE-CODE | Not Applicable | NA | Eligible individuals who are not pregnant cannot have claims with procedures pertaining to labor and delivery. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT169-0005 |
| 2153 | COT170 | PROCEDURE-CODE-DATE | The date upon which the procedure was performed. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT170-0001 |
| 2154 | COT170 | PROCEDURE-CODE-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT170-0002 |
| 2155 | COT170 | PROCEDURE-CODE-DATE | Not Applicable | NA | If the corresponding procedure code is left blank or space-filled then this procedure code date must be blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT170-0003 |
| 2156 | COT170 | PROCEDURE-CODE-DATE | Not Applicable | NA | Date must occur before the ENDING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT170-0004 |
| 2157 | COT170 | PROCEDURE-CODE-DATE | Not Applicable | NA | Date must occur on or after the BEGINNING-DATE-OF-SERVICE. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT170-0005 |
| 2158 | COT170 | PROCEDURE-CODE-DATE | Not Applicable | NA | This date must occur on or before the DATE-OF-DEATH in the Eligible file. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT170-0006 |
| 2159 | COT171 | PROCEDURE-CODE-FLAG | A flag that identifies the coding system used for the PROCEDURE-CODE. | Required | Value must be equal to a valid value. | 01 CPT 4 02 ICD-9 CM 06 HCPCS (Both National and Regional HCPCS) 07 ICD-10-PCS (Will be implemented on 10/1/2014) 10 87 Other Systems 88 Not Applicable 99 Unknown |
8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT171-0001 |
| 2160 | COT171 | PROCEDURE-CODE-FLAG | Not Applicable | NA | If no principal procedure was performed, leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT171-0002 |
| 2161 | COT172 | PROCEDURE-CODE-MOD-1 | A field to capture a modifier code associated with the PROCEDURE-CODE field on the OT claim line. If more than one modifier is reported, the additional codes should be captured in fields "PROCEDURE-CODE-MOD-2" through "PROCEDURE-CODE-MOD-4. | Conditional | All UNUSED diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Valid values are supplied by the state. | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT172-0001 |
| 2162 | COT172 | PROCEDURE-CODE-MOD-1 | Not Applicable | NA | Not Applicable | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT172-0003 |
| 2163 | COT173 | IMMUNIZATION-TYPE | This field identifies the type of immunization provided in order to track additional detail not currently contained in CPT codes. | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT173-0001 |
| 2164 | COT174 | BILLED-AMT | The amount billed at the claim detail level as submitted by the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT174-0001 |
| 2165 | COT174 | BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed the managed care plan. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT174-0002 |
| 2166 | COT175 | ALLOWED-AMT | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT175-0001 |
| 2167 | COT176 | COPAY-AMT | The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT176-0001 |
| 2168 | COT177 | TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT177-0001 |
| 2169 | COT178 | MEDICAID-PAID-AMT | The amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim detail level. | Required | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed the managed care plan. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT178-0001 |
| 2170 | COT178 | MEDICAID-PAID-AMT | Not Applicable | NA | For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT178-0002 |
| 2171 | COT178 | MEDICAID-PAID-AMT | Not Applicable | NA | For Crossover claims with Medicare Coinsurance and/or Deductibles, enter the sum of those amounts in the Medicaid-Amount-Paid field, if the providers were reimbursed by Medicaid for them. If the Coinsurance and Deductibles were not paid by the state, then report the Medicaid-Amount-Paid as $0 | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT178-0003 |
| 2172 | COT178 | MEDICAID-PAID-AMT | Not Applicable | NA | If TYPE‐OF‐CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT178-0004 |
| 2173 | COT179 | MEDICAID-FFS-EQUIVALENT-AMT | The MEDICAID-FFS-EQUIVALENT-AMT field should be populated with the amount that would have been paid had the services been provided on a FFS basis. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT179-0001 |
| 2174 | COT179 | MEDICAID-FFS-EQUIVALENT-AMT | Not Applicable | NA | Required when TYPE-OF-CLAIM = C, 3, or W | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT179-0002 |
| 2175 | COT182 | MEDICARE-PAID-AMT | The amount paid by Medicare on this claim or adjustment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT182-0001 |
| 2176 | COT182 | MEDICARE-PAID-AMT | Not Applicable | NA | If the service was covered by Medicare but Medicare had no liability for the bill, zero-fill. MEDICARE-PAID-AMT should reflect the actual amount paid by Medicare. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT182-0002 |
| 2177 | COT182 | MEDICARE-PAID-AMT | Not Applicable | NA | For claims where Medicare payment is only available at the header level, report the entire payment amount the MSIS record corresponding to the line item with the highest charge. Zero fill Medicare Amount Paid on all other MSIS records created from the original claim. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT182-0003 |
| 2178 | COT182 | MEDICARE-PAID-AMT | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT182-0004 |
| 2179 | COT183 | OT-RX-CLAIM-QUANTITY-ACTUAL | The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span. | Required | Must be numeric | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT183-0001 |
| 2180 | COT183 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT183-0002 |
| 2181 | COT183 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | Left-fill field with zeros if value is less than 9 bytes long. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT183-0003 |
| 2182 | COT183 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | NOTE: One prescription for 100 250 milligram tablets results in QUANTITY OF SERVICE=100. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT183-0004 |
| 2183 | COT183 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | The value in OT-RX-CLAIM-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT183-0005 |
| 2184 | COT183 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT183-0006 |
| 2185 | COT184 | OT-RX-CLAIM-QUANTITY-ALLOWED | The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. | Conditional | Must be numeric | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT184-0001 |
| 2186 | COT184 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT184-0002 |
| 2187 | COT184 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | Left-fill field with zeros if value is less than 9 bytes long. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT184-0003 |
| 2188 | COT184 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT184-0004 |
| 2189 | COT184 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT184-0005 |
| 2190 | COT184 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT184-0006 |
| 2191 | COT186 | TYPE-OF-SERVICE | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0001 |
| 2192 | COT186 | TYPE-OF-SERVICE | Not Applicable | NA | All claims for inpatient psychiatric care provided in a separately administered psychiatric wing or psychiatric hospital are included in the CLAIMLT file. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0002 |
| 2193 | COT186 | TYPE-OF-SERVICE | Not Applicable | NA | Experience has demonstrated there can be instances when more than one service area category could be applicable for a provided service. The following hierarchy rules apply to these instances: The specific service categories of sterilizations and other pregnancy-related procedures take precedence over provider categories, such as inpatient hospital or outpatient hospital. Services of a physician employed by a clinic are reported under clinic services if the clinic is the billing entity. X-rays processed by the clinic in the course of treatment, however, are reported under X-ray services. Services of a registered nurse attending a resident in a NF are reported (if they qualified under the coverage rules) under home health services if they were not billed as part of the NF bill. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0003 |
| 2194 | COT186 | TYPE-OF-SERVICE | Not Applicable | NA | See Appendix D for information on the various types of service. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0004 |
| 2195 | COT186 | TYPE-OF-SERVICE | Not Applicable | NA | Other Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE= 002, 003, 004, 005, 006, 007, 008, 010, 011, 012, 013, 014, 015, 016, 017, 018, 019, 020, 021, 022, 023, 024, 025, 026, 027, 028, 029, 030, 031, 032, 035, 036, 037, 038, 039, 040, 041, 042, 043, 049, 050, 051, 052, 053, 054, 055, 056, 057, 060, 061, 062, 063, 064, 065, 066, 067, 068, 069, 070, 071, 072, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083, 084, 085, 087, 088, 089, 115, 119, 120, 121, 122, 123, 127, 131, 134, or 135. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0005 |
| 2196 | COT186 | TYPE-OF-SERVICE | Not Applicable | NA | Males cannot receive midwife services or other pregnancy-related procedures. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0006 |
| 2197 | COT186 | TYPE-OF-SERVICE | Not Applicable | NA | Capitation payments (TYPE-OF-CLAIM=2, B, V) for non-emergency medical transportation (NEMT) should be reported with TYPE-OF-SERVICE=122 | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0007 |
| 2198 | COT186 | TYPE-OF-SERVICE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non‐Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T‐MSIS Managed Care File" | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT186-0008 |
| 2199 | COT187 | HCBS-SERVICE-CODE | Codes indicating that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes are to help clearly delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services). | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT187-0001 |
| 2200 | COT188 | HCBS-TAXONOMY | A code that classifies home and community based services listed on the claim into the HCBS taxonomy. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT188-0001 |
| 2201 | COT188 | HCBS-TAXONOMY | Not Applicable | NA | If HCBS-SERVICE-CODE = 1 through 8, then populate HCBS-TAXONOMY with one of the values from the list in Appendix B. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT188-0002 |
| 2202 | COT188 | HCBS-TAXONOMY | Not Applicable | NA | If HCBS-SERVICE-CODE = 9 (It is unknown what authority the HCBS service was provided), then populate HCBS-TAXONOMY based on the assumption that the services is not a 1915(j), 1915(k), 1915(c) waiver, or 1115 waiver service. (See “If HCBS-SERVICE-CODE = 1 through 8” above.) | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT188-0003 |
| 2203 | COT189 | SERVICING-PROV-NUM | A unique number to identify the provider who treated the recipient. |
Required | If value is invalid, record it exactly as it appears in the state system. | Valid values are supplied by the state. | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0001 |
| 2204 | COT189 | SERVICING-PROV-NUM | Not Applicable | NA | For institutional providers (TYPE-OF-SERVICE = 002,003, 004 028) and other providers operating as a group, The SERVICING-PROV-NUM should be for the individual who rendered the service. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0002 |
| 2205 | COT189 | SERVICING-PROV-NUM | Not Applicable | NA | If “Servicing” provider and the “Billing” provider are the same then use the same number in both fields. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0003 |
| 2206 | COT189 | SERVICING-PROV-NUM | Not Applicable | NA | Note: Once a national provider ID numbering system is in place, the national number should be used. If only the state’s legacy ID number is available then that number can be entered in this field. |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0004 |
| 2207 | COT189 | SERVICING-PROV-NUM | Not Applicable | NA | Leave blank or space-fill field for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0005 |
| 2208 | COT189 | SERVICING-PROV-NUM | Not Applicable | NA | The value reported in SERVICING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0006 |
| 2209 | COT189 | SERVICING-PROV-NUM | Not Applicable | NA | The value reported in SERVICING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0007 |
| 2210 | COT189 | SERVICING-PROV-NUM | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT189-0008 |
| 2211 | COT190 | SERVICING-PROV-NPI-NUM | The National Provider ID (NPI) of the rendering/attending provider responsible for the beneficiary. | Conditional | The value must consist of digits 0 through 9 only | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT190-0001 |
| 2212 | COT190 | SERVICING-PROV-NPI-NUM | Not Applicable | NA | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT190-0002 |
| 2213 | COT190 | SERVICING-PROV-NPI-NUM | Not Applicable | NA | The field should be blank if the transaction is for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122). | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT190-0004 |
| 2214 | COT191 | SERVICING-PROV-TAXONOMY | The taxonomy code for the provider who treated the recipient. | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT191-0001 |
| 2215 | COT191 | SERVICING-PROV-TAXONOMY | Not Applicable | NA | Leave blank or space-fill field for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122) | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT191-0002 |
| 2216 | COT191 | SERVICING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT191-0003 |
| 2217 | COT192 | SERVICING-PROV-TYPE | A code describing the type of provider (i.e. doctor or facility) who treated the patient. If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided. |
Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT192-0001 |
| 2218 | COT193 | SERVICING-PROV-SPECIALTY | This code indicates the area of specialty for the servicing provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT193-0001 |
| 2219 | COT194 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT194-0001 |
| 2220 | COT195 | TOOTH-DESIGNATION-SYSTEM | A code to identify the tooth numbering system is being used. | Conditional | Enter the value that corresponds to the tooth designation system used to populate the TOOTH-NUMBER, AREA-OF-ORAL-CAVITY, and TOOTH-SURFACE-CODE data elements. | JO ANSI/ADA/ISO Specification No. 3950 JP ADA’s Universal/National Tooth Designation system |
2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT195-0001 |
| 2221 | COT196 | TOOTH-NUM | The tooth number serviced based on the tooth numbering system identified in the TOOTH-DESIGNATION-SYSTEM field. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT196-0001 |
| 2222 | COT196 | TOOTH-NUM | Not Applicable | NA | If JO tooth designation system is used: Permanent Upper right quad medial to distal: 11-18 Permanent Upper left quad medial to distal: 22-28 Permanent lower right quad medial to distal: 41-48 Permanent lower left quad medial to distal: 31-38 Primary/Deciduous upper right quad medial to distal: 51-55 Primary/Deciduous upper left quad medial to distal: 61-65 Primary/Deciduous lower left quad medial to distal: 71-75 Primary/Deciduous lower right quad medial to distal: 81-85 |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT196-0002 |
| 2223 | COT196 | TOOTH-NUM | Not Applicable | NA | If JP tooth designation system is used: (Source: "Current Dental Terminology, CDT 2009 - 2010", American Dental Association). |
Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT196-0003 |
| 2224 | COT196 | TOOTH-NUM | Not Applicable | NA | If the first character of TOOTH-NUM is A through T then beneficiary age must be < 15. (Deciduous teeth are usually all gone by age 12.) | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT196-0004 |
| 2225 | COT196 | TOOTH-NUM | Not Applicable | NA | If TOOTH-NUM <> missing then TYPE-OF-SERVICE must = Dental | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT196-0005 |
| 2226 | COT196 | TOOTH-NUM | Not Applicable | NA | If more than one tooth number is applicable to a single claim line then report the first tooth value here. When T-MSIS was first implemented only one occurrence of tooth number could be reported per claim line. The T-MSIS layout was enhanced as of [TBD] to allow for multiple tooth numbers per line. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable |
| 2227 | COT197 | TOOTH-QUAD-CODE | The area of the oral cavity is designated by a two-digit code. |
Conditional | Value must be equal to a valid value. | 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 |
11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT197-0001 |
| 2228 | COT197 | TOOTH-QUAD-CODE | Not Applicable | NA | IF TOOTH-QUAD-CODE <> missing then TYPE-OF-SERVICE must = Dental | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT197-0002 |
| 2229 | COT197 | TOOTH-QUAD-CODE | Not Applicable | NA | If more than one tooth quadrant is applicable to a single claim line then report the first quadrant value here. When T-MSIS was first implemented only one occurrence of tooth quadrant could be reported per claim line. The T-MSIS layout was enhanced as of [TBD] to allow for multiple tooth quadrants per line. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable |
| 2230 | COT198 | TOOTH-SURFACE-CODE | A code to identify the tooth’s surface on which the service was performed. |
Conditional | Value must be equal to a valid value. | 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. |
11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT198-0001 |
| 2231 | COT198 | TOOTH-SURFACE-CODE | Not Applicable | NA | IF TOOTH-SURFACE-CODE <> missing then TYPE-OF-SERVICE must = Dental | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT198-0002 |
| 2232 | COT198 | TOOTH-SURFACE-CODE | Not Applicable | NA | If more than one tooth surface is applicable to a single claim line then report the first surface value here. When T-MSIS was first implemented only one occurrence of tooth surface could be reported per claim line. The T-MSIS layout was enhanced as of [TBD] to allow for multiple tooth surfaces per line. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable |
| 2233 | COT199 | ORIGINATION-ADDR-LN1 | The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT199-0001 |
| 2234 | COT199 | ORIGINATION-ADDR-LN1 | Not Applicable | NA | For transportation claims, this is only required if state has captured this information, otherwise it is conditional | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT199-0002 |
| 2235 | COT200 | ORIGINATION-ADDR-LN2 | The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT200-0001 |
| 2236 | COT200 | ORIGINATION-ADDR-LN2 | Not Applicable | NA | For transportation claims, this is only required if state has captured this information, otherwise it is conditional | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT200-0002 |
| 2237 | COT200 | ORIGINATION-ADDR-LN2 | Not Applicable | NA | When this data element is not populated or used, States must Leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT200-0003 |
| 2238 | COT201 | ORIGINATION-CITY | The name of the origination city from which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT201-0001 |
| 2239 | COT201 | ORIGINATION-CITY | Not Applicable | NA | For transportation claims, this is only required if state has captured this information, otherwise it is conditional | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT201-0002 |
| 2240 | COT202 | ORIGINATION-STATE | The ANSI 2 numeric code of the origination state in which a patient is transported either from home or a long term care facility to a health care provider to a health care provider for healthcare services or vice versa. | Conditional | Value must be equal to a valid value. | http://www.census.gov/geo/reference/ansi_statetables.html | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT202-0001 |
| 2241 | COT202 | ORIGINATION-STATE | Not Applicable | NA | A value is required transportation claims | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT202-0002 |
| 2242 | COT203 | ORIGINATION-ZIP-CODE | The zip code of the origination city from which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The value must consist of digits 0 through 9 only | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT203-0001 |
| 2243 | COT203 | ORIGINATION-ZIP-CODE | Not Applicable | NA | This is only required if state has captured this information, otherwise it is conditional. If the last 4 digits are not populated or used, then the 4-digit extended zip code should be recorded as “0000”. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT203-0002 |
| 2244 | COT204 | DESTINATION-ADDR-LN1 | The street address of the destination point to which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT204-0001 |
| 2245 | COT204 | DESTINATION-ADDR-LN1 | Not Applicable | NA | For transportation claims only. Required if state has captured this information, otherwise it is conditional. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT204-0002 |
| 2246 | COT205 | DESTINATION-ADDR-LN2 | The street address of the destination point to which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT205-0001 |
| 2247 | COT205 | DESTINATION-ADDR-LN2 | Not Applicable | NA | For transportation claims only. Required if state has captured this information, otherwise it is conditional. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT205-0002 |
| 2248 | COT205 | DESTINATION-ADDR-LN2 | Not Applicable | NA | When this data element is not populated or used, States must Leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT205-0003 |
| 2249 | COT206 | DESTINATION-CITY | The name of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT206-0001 |
| 2250 | COT206 | DESTINATION-CITY | Not Applicable | NA | For transportation claims only. This field is required if state has captured this information, otherwise it is conditional. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT206-0002 |
| 2251 | COT207 | DESTINATION-STATE | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. | Conditional | Value must be equal to a valid value. | http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT207-0001 |
| 2252 | COT207 | DESTINATION-STATE | Not Applicable | NA | For transportation claims only. This field is required if state has captured this information, otherwise it is conditional. | Not Applicable | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT207-0002 |
| 2253 | COT208 | DESTINATION-ZIP-CODE | The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. | Conditional | The value must consist of digits 0 through 9 only | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT208-0001 |
| 2254 | COT208 | DESTINATION-ZIP-CODE | Not Applicable | NA | This field is required if state has captured this information, otherwise it is conditional. If the last 4 digits are not populated or used, then the 4-digit extended zip code should be recorded as “0000”. | Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT208-0002 |
| 2255 | COT209 | BENEFIT-TYPE | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System’s (MACPro’s) benefit type list. See Appendix H: Benefit Types for descriptions of the categories. |
Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 2/25/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT209-0001 |
| 2256 | COT210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | This code indicates if the claim was matched with Title XIX or Title XXI. | Required | Value must be equal to a valid value. | 01 Federal funding under Title XIX 02 Federal funding under Title XXI 03 Federal funding under ACA 04 Federal funding under other legislation |
4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT210-0001 |
| 2257 | COT210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT210-0002 |
| 2258 | COT210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for Medicaid, then any associated claims records should not have reimbursed with federal funding under Title XIX. | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT210-0003 |
| 2259 | COT211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation. | Conditional | Value must be equal to a valid value. | See Appendix I for listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT211-0001 |
| 2260 | COT211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | Not Applicable | NA | Males cannot receive services where the category of service is "Other Pregnancy-related Procedures", "Nurse Mid-wife", "Freestanding Birth Center" or "Tobacco Cessation for Pregnant Women". | Not Applicable | 4/30/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT211-0002 |
| 2261 | COT212 | XXI-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. Refer to Attachment 8 for definitions on the various categories of service. | Conditional | Value must be equal to a valid value. | See Appendix J for listing of valid values. | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT212-0001 |
| 2262 | COT213 | OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT213-0001 |
| 2263 | COT214 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT214-0001 |
| 2264 | COT214 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT214-0002 |
| 2265 | COT215 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT215-0001 |
| 2266 | COT216 | SEQUENCE-NUMBER | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' SUBMISSION-TRANSACTION-TYPE record files. | Not Applicable | 8/7/2017 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT216-0001 |
| 2267 | COT216 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | COT216-0002 |
| 2268 | COT217 | NATIONAL-DRUG-CODE | A code in National Drug Code (NDC) format indicating the drug, device, or medical supply covered by this claim. | Conditional | Position 10-11 must be Alpha Numeric or blank | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT217-0001 |
| 2269 | COT217 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 1-5 must be Numeric | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT217-0002 |
| 2270 | COT217 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 6-9 must be Alpha Numeric | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT217-0003 |
| 2271 | COT217 | NATIONAL-DRUG-CODE | Not Applicable | NA | Drug code formats must be supplied by State in advance of submitting any file data. States must inform CMS of the NDC segments used and their size (e.g., {5, 4, 2} or {5, 4} as defined in the National Drug Code Directory). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT217-0004 |
| 2272 | COT217 | NATIONAL-DRUG-CODE | Not Applicable | NA | If the Drug Code is less than 11 characters in length, the value must be left justified and padded with spaces. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT217-0005 |
| 2273 | COT217 | NATIONAL-DRUG-CODE | Not Applicable | NA | If Durable Medical Equipment or supply is prescribed by a physician and provided by a pharmacy then HCPCS or state specific codes can be put in the NDC field. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT217-0006 |
| 2274 | COT217 | NATIONAL-DRUG-CODE | Not Applicable | NA | This field is applicable only for TYPE-OF-SERVICE = 035, 036, 077, 062, 063, 064, 065, 066, 067, 068, 069, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083, 084, 033, 034. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT217-0007 |
| 2275 | COT218 | PROCEDURE-CODE-MOD-3 | A field to capture a modifier code associated with the PROCEDURE-CODE field on the OT claim line. If more than one modifier is reported, the additional codes should be captured in fields "PROCEDURE-CODE-MOD-2" through "PROCEDURE-CODE-MOD-4. |
Conditional | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Valid values are supplied by the state. | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT218-0001 |
| 2276 | COT218 | PROCEDURE-CODE-MOD-3 | Not Applicable | NA | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT218-0004 |
| 2277 | COT218 | PROCEDURE-CODE-MOD-3 | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT218-0005 |
| 2278 | COT219 | PROCEDURE-CODE-MOD-4 | A field to capture a modifier code associated with the PROCEDURE-CODE field on the OT claim line. If more than one modifier is reported, the additional codes should be captured in fields "PROCEDURE-CODE-MOD-2" through "PROCEDURE-CODE-MOD-4. |
Conditional | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Valid values are supplied by the state. | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT219-0001 |
| 2279 | COT219 | PROCEDURE-CODE-MOD-4 | Not Applicable | NA | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT219-0004 |
| 2280 | COT219 | PROCEDURE-CODE-MOD-4 | Not Applicable | NA | Not Applicable | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT219-0005 |
| 2281 | COT220 | HCPCS-RATE | For outpatient hospital facility claims, HCPCS/CPT is captured here. This data element is expected to capture data from HIPAA 837I claim loop 2400 SV202 or UB-04 FL 44 (only if the value represents a HCPCS/CPT). If HCPCS-RATE is populated then PROCEDURE-CODE should not be populated. | Conditional | Value must be equal to a valid value. | http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/medhcpcsgeninfo/ | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT220-0001 |
| 2282 | COT221 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0001 |
| 2283 | COT221 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0002 |
| 2284 | COT221 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0003 |
| 2285 | COT221 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0004 |
| 2286 | COT221 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0005 |
| 2287 | COT221 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or after the ADMISSION-DATE | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0006 |
| 2288 | COT221 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record when the eligible is not a CHIP unborn child. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0007 |
| 2289 | COT221 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT221-0008 |
| 2290 | COT222 | SELF-DIRECTION-TYPE | A data element to identify how the beneficiary self-directed the service, i.e. Hiring Authority (the beneficiary has decision-making authority to recruit, hire, train and supervise the individuals who furnish his/her services), Budget Authority (The beneficiary has decision-making authority over how the Medicaid funds in a budget are spent), or both Hiring and Budget Authority. | Conditional | Value must be equal to a valid value. | 000 Not Applicable 001 Hiring Authority 002 Budget Authority 003 Hiring and Budget Authority |
8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT222-0001 |
| 2291 | COT223 | PRE-AUTHORIZATION-NUM | A number, code, or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also called Prior Authorization or Referral Number). | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT223-0001 |
| 2292 | COT224 | NDC-UNIT-OF-MEASURE | A code to indicate the basis by which the quantity of the National Drug Code is expressed. |
Conditional | Value must be equal to a valid value. Valid Value Definition: F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit |
F2 International Unit ML Milliliter GR Gram ME Milligram UN Unit |
8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT224-0001 |
| 2293 | COT224 | NDC-UNIT-OF-MEASURE | Not Applicable | NA | Enter the unit of measure for each corresponding quantity value. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT224-0002 |
| 2294 | COT225 | NDC-QUANTITY | This field is to capture the actual quantity of the National Drug Code being prescribed on this out-patient claim. | Conditional | Must be numeric | Not Applicable | 11/3/2015 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT225-0001 |
| 2295 | COT225 | NDC-QUANTITY | Not Applicable | NA | This field is only applicable when the NDC code being billed can be quantified in discrete units, e.g., the number of units of a prescription/refill that were filled. | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT225-0002 |
| 2296 | COT226 | PROV-LOCATION-ID | A code to uniquely identify the geographic location where the provider’s services were performed. The value should correspond to an active value in the PROV-LOCATION-ID field in the provider subject area. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT226-0001 |
| 2297 | COT226 | PROV-LOCATION-ID | Not Applicable | NA | The value should correspond with one of the location identifiers recorded in the provider’s demographic records in the T-MSIS data set. If a particular license is applicable to all locations, create an identifier that signifies "All Locations" | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | COT226-0002 |
| 2298 | COT227 | PROCEDURE-CODE-MOD-2 | A field to capture a modifier code associated with the PROCEDURE-CODE field on the OT claim line. If more than one modifier is reported, the additional codes should be captured in fields "PROCEDURE-CODE-MOD-2" through "PROCEDURE-CODE-MOD-4. | Conditional | If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill | Valid values are supplied by the state. | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT227-0001 |
| 2299 | COT227 | PROCEDURE-CODE-MOD-2 | Not Applicable | NA | Do not use multiple instances of PROCEDURE-CODE-MOD if the preceding PROCEDURE-CODE-MOD element is not populated. (i.e. if PROCEDURE-CODE-MOD-2 is populated, but PROCEDURE-CODE-MOD-3 is blank-filled, then PROCEDURE-CODE-MOD-4 must also not be valued. | Not Applicable | 8/7/2017 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT227-0002 |
| 2300 | COT227 | PROCEDURE-CODE-MOD-2 | Not Applicable | NA | Not Applicable | Not Applicable | 10/10/2013 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | COT227-0005 |
| 2301 | CRX001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002. | Required | Value must be equal to a valid value. | CRX00001 | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX001-0001 |
| 2302 | CRX001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX001-0002 |
| 2303 | CRX002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX002-0001 |
| 2304 | CRX003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX003-0001 |
| 2305 | CRX003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2306 | CRX004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or delimited format. | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
4/30/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX004-0001 |
| 2307 | CRX005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document | Not Applicable | 2/25/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX005-0001 |
| 2308 | CRX006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Value must be equal to a valid value. | CLAIM-RX - Pharmacy Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 011, 018, 033, 034, 036, 085, 089, 127, or 131. |
8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX006-0001 |
| 2309 | CRX006 | FILE-NAME | Not Applicable | NA | For TYPE-OF-SERVICE = 011, 018, 033, 034, 036, 085, 089, 127, or 13, FILE-NAME must be CLAIM-RX. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2310 | CRX007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX007-0001 |
| 2311 | CRX007 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX007-0002 |
| 2312 | CRX007 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX007-0003 |
| 2313 | CRX007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX007-0004 |
| 2314 | CRX008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 2/25/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX008-0001 |
| 2315 | CRX008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX008-0002 |
| 2316 | CRX008 | DATE-FILE-CREATED | Not Applicable | NA | Required on every file header | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2317 | CRX008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field. |
Not Applicable | 2/25/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX008-0003 |
| 2318 | CRX009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX009-0001 |
| 2319 | CRX009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2320 | CRX009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX009-0002 |
| 2321 | CRX009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2322 | CRX009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2323 | CRX009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2324 | CRX010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. | Required | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 2/25/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX010-0001 |
| 2325 | CRX010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX010-0002 |
| 2326 | CRX010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2327 | CRX010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2328 | CRX010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than DATE-FILE-CREATED. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2329 | CRX010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be greater than START-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2330 | CRX011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX011-0001 |
| 2331 | CRX011 | FILE-STATUS-INDICATOR | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2332 | CRX011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2333 | CRX012 | SSN-INDICATOR | Indicates whether the state uses the eligible person's social security number (SSN) instead of an MSIS identification number as the unique, unchanging eligible person identifier. | Required | Value must be equal to a valid value. | 0 State does not use SSN as MSIS-IDENTIFICATION-NUMBER 1 State uses SSN as MSIS-IDENTIFICATION-NUMBER |
4/30/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX012-0001 |
| 2334 | CRX012 | SSN-INDICATOR | Not Applicable | NA | A state's SSN/Non-SSN designation on the eligibility file should match on the claims files. | Not Applicable | 4/30/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX012-0002 |
| 2335 | CRX012 | SSN-INDICATOR | Not Applicable | NA | For non-SSN states, the SSN-INDICATOR in the Header record must be set to 0 and the MSIS identification number must be reported in the MSIS-IDENTIFICATION-NUMBER field. If the MSIS-IDENTIFICATION-NUMBER is not known then this field should be 9-filled, left blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2336 | CRX013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX013-0001 |
| 2337 | CRX013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable |
| 2338 | CRX014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX014-0001 |
| 2339 | CRX014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX014-0002 |
| 2340 | CRX015 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX015-0001 |
| 2341 | CRX016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002. | Required | Value must be equal to a valid value. | CRX00002 | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX016-0001 |
| 2342 | CRX016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX016-0002 |
| 2343 | CRX017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX017-0001 |
| 2344 | CRX017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX017-0002 |
| 2345 | CRX017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX017-0003 |
| 2346 | CRX017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX017-0004 |
| 2347 | CRX018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX018-0001 |
| 2348 | CRX018 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX018-0002 |
| 2349 | CRX018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX018-0004 |
| 2350 | CRX019 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX019-0001 |
| 2351 | CRX019 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the state system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX019-0002 |
| 2352 | CRX019 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX019-0003 |
| 2353 | CRX019 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2354 | CRX020 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX020-0001 |
| 2355 | CRX020 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX020-0002 |
| 2356 | CRX020 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX020-0003 |
| 2357 | CRX021 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to state’s claim adjudication system. | Required | Value must not be null | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX021-0001 |
| 2358 | CRX022 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX022-0001 |
| 2359 | CRX022 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX022-0003 |
| 2360 | CRX022 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the state ID numbers must be supplied to CMS. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX022-0002 |
| 2361 | CRX023 | CROSSOVER-INDICATOR | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Required | Value must be equal to a valid value. | 0 Not Crossover Claim 1 Crossover Claim |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX023-0001 |
| 2362 | CRX023 | CROSSOVER-INDICATOR | Not Applicable | NA | If Crossover Indicator is Yes, there must be Medicare enrollment in the Eligible file for the same time period (by date of service). | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX023-0002 |
| 2363 | CRX023 | CROSSOVER-INDICATOR | Not Applicable | NA | Detail records should be created for all crossover claims. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX023-0003 |
| 2364 | CRX024 | 1115A-DEMONSTRATION-IND | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX024-0001 |
| 2365 | CRX025 | ADJUSTMENT-IND | Code indicating the type of adjustment record. | Required | Value must be equal to a valid value. |
0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX025-0001 |
| 2366 | CRX025 | ADJUSTMENT-IND | Not Applicable | NA | ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "3", "5", "A", "C", "E", "U", "W", "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX025-0002 |
| 2367 | CRX026 | ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. | Conditional | Value must be in the set of valid values | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX026-0001 |
| 2368 | CRX026 | ADJUSTMENT-REASON-CODE | Not Applicable | NA | if there is no adjustment to a claim, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE). | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX026-0002 |
| 2369 | CRX027 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX027-0001 |
| 2370 | CRX027 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX027-0002 |
| 2371 | CRX027 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX027-0003 |
| 2372 | CRX027 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX027-0004 |
| 2373 | CRX027 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX027-0005 |
| 2374 | CRX027 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record when the eligible is not a CHIP unborn child. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX027-0006 |
| 2375 | CRX027 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX027-0007 |
| 2376 | CRX028 | MEDICAID-PAID-DATE | The date Medicaid paid on this claim or adjustment. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX028-0001 |
| 2377 | CRX028 | MEDICAID-PAID-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX028-0002 |
| 2378 | CRX029 | TYPE-OF-CLAIM | A code indicating what kind of payment is covered in this claim. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX029-0001 |
| 2379 | CRX029 | TYPE-OF-CLAIM | Not Applicable | NA | States should only submit CHIP claims for CHIP eligibles | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX029-0002 |
| 2380 | CRX029 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the basis of eligibility. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX029-0003 |
| 2381 | CRX029 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the maintenance assistance status. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX029-0004 |
| 2382 | CRX029 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the restricted benefits code. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX029-0005 |
| 2383 | CRX029 | TYPE-OF-CLAIM | Not Applicable | NA | States should not submit any Medicaid claims records for individuals who were not eligible for Medicaid according to the TANF code. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX029-0006 |
| 2384 | CRX030 | CLAIM-STATUS | The health care claim status codes convey the status of an entire claim. |
Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX030-0001 |
| 2385 | CRX030 | CLAIM-STATUS | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2386 | CRX031 | CLAIM-STATUS-CATEGORY | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.), which is then further detailed in the companion data element CLAIM-STATUS. | Required | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/ | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX031-0001 |
| 2387 | CRX031 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All denied claims should have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2388 | CRX031 | CLAIM-STATUS-CATEGORY | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2389 | CRX032 | SOURCE-LOCATION | The field denotes the claim payment system from which the claim was adjudicated. | Required | Value must be equal to a valid value. | 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) |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX032-0001 |
| 2390 | CRX033 | CHECK-NUM | The check or EFT number. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX033-0001 |
| 2391 | CRX033 | CHECK-NUM | Not Applicable | NA | If there is a valid check date there should also be a valid check number. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX033-0002 |
| 2392 | CRX034 | CHECK-EFF-DATE | Date the check is issued to the payee, or if Electronic Funds Transfer (EFT), the date the transfer is made. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2393 | CRX034 | CHECK-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2394 | CRX034 | CHECK-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX034-0002 |
| 2395 | CRX034 | CHECK-EFF-DATE | Not Applicable | NA | Could be the same as Remittance Date. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX034-0003 |
| 2396 | CRX034 | CHECK-EFF-DATE | Not Applicable | NA | If there is a valid check number, there should also be a valid check date. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX034-0004 |
| 2397 | CRX035 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX035-0001 |
| 2398 | CRX036 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX036-0001 |
| 2399 | CRX037 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX037-0001 |
| 2400 | CRX038 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | Conditional | Value must be equal to a valid value. | Use the Remittance Advice Remark Codes at the following link: http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX038-0001 |
| 2401 | CRX039 | TOT-BILLED-AMT | The total amount billed for this claim at the claim header level as submitted by the provider. | Conditional | TOT-BILLED-AMT must be a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX039-0001 |
| 2402 | CRX039 | TOT-BILLED-AMT | Not Applicable | NA | The total amount should be the sum of each of the billed amounts submitted at the claim detail level. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX039-0002 |
| 2403 | CRX039 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000". | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX039-0003 |
| 2404 | CRX039 | TOT-BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed the managed care plan. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX039-0004 |
| 2405 | CRX040 | TOT-ALLOWED-AMT | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. | Conditional | TOT-ALLOWED-AMT must be a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX040-0001 |
| 2406 | CRX040 | TOT-ALLOWED-AMT | Not Applicable | NA | The sum of the allowed amounts at the detailed levels must equal TOT-ALLOWED-AMT | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX040-0002 |
| 2407 | CRX041 | TOT-MEDICAID-PAID-AMT | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Required | If TYPE-OF-CLAIM = 1 or A (fee-for-service claim) this field should be populated with the amount that the Medicaid agency paid to the provider. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX041-0001 |
| 2408 | CRX041 | TOT-MEDICAID-PAID-AMT | Not Applicable | NA | If TYPE‐OF‐CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX041-0002 |
| 2409 | CRX042 | TOT-COPAY-AMT | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX042-0001 |
| 2410 | CRX043 | TOT-MEDICARE-DEDUCTIBLE-AMT | The amount paid by Medicaid/CHIP on this claim at the claim header level toward the beneficiary’s Medicare deductible. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX043-0001 |
| 2411 | CRX043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code MEDICARE-COMB-DED-IND with a "1", and code space in TOT-MEDICARE-COINS-AMT. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX043-0002 |
| 2412 | CRX043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | The total Medicare deductible amount must be less than or equal the total billed amount. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX043-0003 |
| 2413 | CRX044 | TOT-MEDICARE-COINS-AMT | The amount paid by Medicaid/CHIP on this claim at the claim header level toward the beneficiary’s Medicare coinsurance | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX044-0001 |
| 2414 | CRX044 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | Value must be less than TOT-BILLED-AMT. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2415 | CRX044 | TOT-MEDICARE-COINS-AMT | Not Applicable | NA | If the Medicare coinsurance amount can be identified separately from Medicare deductible amount, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, code space in this field, code MEDICARE-COMB-DED-IND with a "1", and fill the combined payment amount in TOT-MEDICARE-DEDUCTIBLE-AMT | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX044-0002 |
| 2416 | CRX045 | TOT-TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX045-0001 |
| 2417 | CRX045 | TOT-TPL-AMT | Not Applicable | NA | The TOT-TPL-AMT should be =< TOT-BILLED-AMT - (minus) (TOT-MEDICARE-COINS-AMT + (plus) TOT-MEDICARE-DEDUCTIBLE-AMT). | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX045-0002 |
| 2418 | CRX047 | TOT-OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX047-0001 |
| 2419 | CRX048 | OTHER-INSURANCE-IND | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX048-0001 |
| 2420 | CRX049 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX049-0001 |
| 2421 | CRX050 | SERVICE-TRACKING-TYPE | A code to categorize service tracking claims. A “service tracking claim” is used to report lump sum payments that cannot be attributed to a single enrollee. (Note: Use an encounter record to report services provided under a capitated payment arrangement.) | Conditional | Value must be equal to a valid value. | 00 Not a Service Tracking Claim 01 Drug Rebate 02 DSH Payment 03 Lump Sum Payment 04 Cost Settlement 05 Supplemental 06 Other |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX050-0001 |
| 2422 | CRX050 | SERVICE-TRACKING-TYPE | Not Applicable | NA | This field is required if TYPE-OF-CLAIM equals a service tracking claim (Valid values for service tracking claims include 4, D, X) | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2423 | CRX051 | SERVICE-TRACKING-PAYMENT-AMT | On service tracking claims, the lump sum amount paid to the provider. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX051-0001 |
| 2424 | CRX051 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Amount paid for services received by an individual patient, when the state accepts a lump sum form a provider that covered similar services delivered to more than one patient, such as a group screening for EPSDT. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX051-0002 |
| 2425 | CRX051 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | Required on service tracking records, TYPE-OF-CLAIM equals 4, D, X) | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX051-0003 |
| 2426 | CRX051 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | If there is a service tracking type, then there must also be a service tracking payment amount. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX051-0004 |
| 2427 | CRX051 | SERVICE-TRACKING-PAYMENT-AMT | Not Applicable | NA | For service tracking payments, ensure that the TOT-MEDICAID-PAID-AMOUNT is 0 filled and provide payment amount in SERVICE-TRACKING-PAYMENT-AMT only. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX051-0005 |
| 2428 | CRX052 | FIXED-PAYMENT-IND | This code indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management (PCCM) programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined “medical record” associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Conditional | Value must be equal to a valid value. | 0 Not Fixed Payment 1 FFS Fixed Payment |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX052-0001 |
| 2429 | CRX053 | FUNDING-CODE | A code to indicate the source of non-federal share funds. | Required | Value must be equal to a valid value. | 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 |
10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX053-0001 |
| 2430 | CRX054 | FUNDING-SOURCE-NONFEDERAL-SHARE | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. | Required | Value must be equal to a valid value. When states have multiple sources of FUNDING-SOURCE-NONFEDERAL-SHARE, States are to report the portion which represents the largest proportion as the 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 |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX054-0001 |
| 2431 | CRX055 | PROGRAM-TYPE | Code indicating special Medicaid program under which the service was provided. Refer to Appendix E for information on the various program types. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX055-0001 |
| 2432 | CRX055 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=Community First Choice (11) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 01 for the same time period. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX055-0002 |
| 2433 | CRX055 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=Community First Choice (11) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 01 for the same time period. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX055-0003 |
| 2434 | CRX055 | PROGRAM-TYPE | Not Applicable | NA | If PROGRAM-TYPE=1915(i) (value=13) then [T-MSIS ELIGIBLE FILE] STATE-PLAN-OPTION-TYPE must = 02 for the same time period. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX055-0004 |
| 2435 | CRX055 | PROGRAM-TYPE | Not Applicable | NA | Value for 1915 (c) waiver must correspond to the values for 1915(c) waiver in the Waiver Type. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX055-0005 |
| 2436 | CRX056 | PLAN-ID-NUMBER | A unique number, assigned by the state, which represents the health plan under which the non-fee-for-service encounter was provided including through the state plan and a waiver. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX056-0001 |
| 2437 | CRX056 | PLAN-ID-NUMBER | Not Applicable | NA | use the number as it is carried in the state’s system. (TYPE-OF-CLAIM=3, C, W). |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX056-0002 |
| 2438 | CRX056 | PLAN-ID-NUMBER | Not Applicable | NA | if TYPE-OF-CLAIM<>3, C, W (Encounter Record), leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX056-0003 |
| 2439 | CRX056 | PLAN-ID-NUMBER | Not Applicable | NA | The managed care ID on the individual's eligible record must match that which is included on any claims records (TYPE-OF-CLAIM= 3, C, W) for the eligible individual. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX056-0006 |
| 2440 | CRX056 | PLAN-ID-NUMBER | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File" | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX056-0007 |
| 2441 | CRX057 | NATIONAL-HEALTH-CARE-ENTITY-ID | The national identifier of the health care entity (controlling health plan, subhealth plan, or other entity) at the most granular sub-health plan level of the Medicaid or CHIP health plan in which an individual is enrolled. (See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX057-0001 |
| 2442 | CRX057 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX057-0002 |
| 2443 | CRX057 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | This field is required for all managed care claims and encounters with dates of service on or after the mandated dates above. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX057-0003 |
| 2444 | CRX057 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | NATIONAL-HEALTH-CARE-ENTITY-IDs on managed care claims and encounters must match NATIONAL-HEALTH-CARE-ENTITY-IDs on file for the individual in the eligibility subject area or the TPL subject area. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX057-0004 |
| 2445 | CRX058 | PAYMENT-LEVEL-IND | The field denotes whether the claim payment is made at the header level or the detail level. | Required | Value must be equal to a valid value. | 1 Claim Header – Sum of Line Item payments 2 Claim Detail – Individual Line Item payments |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX058-0001 |
| 2446 | CRX058 | PAYMENT-LEVEL-IND | Not Applicable | NA | Payment fields at either the claim header or line on encounter records should be left blank. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX058-0002 |
| 2447 | CRX059 | MEDICARE-REIM-TYPE | This code indicates the type of Medicare Reimbursement. | Conditional | Value must be equal to a valid value. | 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 |
10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX059-0001 |
| 2448 | CRX059 | MEDICARE-REIM-TYPE | Not Applicable | NA | If this is a crossover Medicare claim (CROSSOVER-IND= 1), the claim must have a MEDICARE-REIM-TYPE. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX059-0002 |
| 2449 | CRX060 | CLAIM-LINE-COUNT | The total number of lines on the claim. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX060-0001 |
| 2450 | CRX060 | CLAIM-LINE-COUNT | Not Applicable | NA | The claim line count should equal the sum of the claim lines for this record. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX060-0002 |
| 2451 | CRX061 | FORCED-CLAIM-IND | This code indicates if the claim was processed by forcing it through a manual override process. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX061-0001 |
| 2452 | CRX062 | PATIENT-CONTROL-NUM | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client’s episode of service within the provider’s system to facilitate retrieval of individual financial and clinical records and posting of payment. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX062-0001 |
| 2453 | CRX063 | ELIGIBLE-LAST-NAME | The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX063-0001 |
| 2454 | CRX063 | ELIGIBLE-LAST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX063-0002 |
| 2455 | CRX064 | ELIGIBLE-FIRST-NAME | The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX064-0001 |
| 2456 | CRX064 | ELIGIBLE-FIRST-NAME | Not Applicable | NA | When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than the eligible person’s name from the T-MSIS Eligible File. | Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX064-0002 |
| 2457 | CRX065 | ELIGIBLE-MIDDLE-INIT | The middle initial of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS-IDENTIFICATION-NUM will be used to associate a claim record with the appropriate eligibility data.) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX065-0001 |
| 2458 | CRX065 | ELIGIBLE-MIDDLE-INIT | Not Applicable | NA | Leave blank if not available When populating the eligible person’s name on T-MSIS Claim Files, use the patient’s name from the claim transaction rather than use the eligible person’s name from the T-MSIS Eligible File. |
Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX065-0002 |
| 2459 | CRX066 | DATE-OF-BIRTH | Date of birth of the individual to whom the services were provided. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX066-0001 |
| 2460 | CRX066 | DATE-OF-BIRTH | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX066-0002 |
| 2461 | CRX066 | DATE-OF-BIRTH | Not Applicable | NA | The numeric form for days and months from 1 to 9 must have a zero as the first digit. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX066-0003 |
| 2462 | CRX066 | DATE-OF-BIRTH | Not Applicable | NA | A patient's age should not be greater than 112 years. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX066-0005 |
| 2463 | CRX067 | HEALTH-HOME-PROV-IND | This code indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX067-0001 |
| 2464 | CRX067 | HEALTH-HOME-PROV-IND | Not Applicable | NA | if a state has not yet begun collecting this information, HEALTH-HOME-PROVIDER-IND, this field should be defaulted to the value “8.” | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX067-0002 |
| 2465 | CRX067 | HEALTH-HOME-PROV-IND | Not Applicable | NA | If there is a HEALTH-HOME-ENTITY-NAME then HEALTH-HOME-PROV-IND must indicate yes. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX067-0003 |
| 2466 | CRX067 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States should not submit claim records for an eligible individual that indicate the claim was submitted by a provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX067-0004 |
| 2467 | CRX067 | HEALTH-HOME-PROV-IND | Not Applicable | NA | States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX067-0005 |
| 2468 | CRX068 | WAIVER-TYPE | Code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Conditional | Enter the WAIVER-TYPE assigned | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX068-0001 |
| 2469 | CRX068 | WAIVER-TYPE | Not Applicable | NA | Value must correspond to associated WAIVER-ID | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX068-0002 |
| 2470 | CRX068 | WAIVER-TYPE | Not Applicable | NA | WAIVER-TYPE on claim must match [T-MSIS ELIGIBLE FILE]WAIVER-TYPE for the enrollee for the same time period (by date of service). | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX068-0003 |
| 2471 | CRX068 | WAIVER-TYPE | Not Applicable | NA | An ineligible individual should not have a category for federal reimbursement for Medicaid or CHIP (CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT <> 01,02) | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX068-0004 |
| 2472 | CRX069 | WAIVER-ID | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. The categories of demonstration and waiver programs include: 1915(b)(1); 1915(b)(2); 1915(b)(3), and 1915(b)(4) managed care waivers; 1915(c) home and community based services waivers; combined 1915(b) and 1915(c) managed home and community based services waivers and 1115 demonstrations. | Conditional | Not Applicable | Valid values are supplied by the state. | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX069-0001 |
| 2473 | CRX069 | WAIVER-ID | Not Applicable | NA | If the goods & services rendered do not fall under a waiver, leave this field blank. | Not Applicable | 11/9/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX069-0002 |
| 2474 | CRX069 | WAIVER-ID | Not Applicable | NA | Report the full federal waiver identifier. | Not Applicable | 11/9/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX069-0003 |
| 2475 | CRX069 | WAIVER-ID | Not Applicable | NA | If there's a waiver type, there should be a corresponding waiver id. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX069-0005 |
| 2476 | CRX070 | BILLING-PROV-NUM | A unique identification number assigned by the state to a provider or capitation plan. This should represent the entity billing for the service. | Required | A list of valid codes should be supplied by the state prior to submission of any file data | Valid values are supplied by the state. | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX070-0001 |
| 2477 | CRX070 | BILLING-PROV-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), this represents the entity billing (or reporting) to the managed care plan (See PLAN-ID-NUMBER for reporting capitation plan-ID). | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX070-0002 |
| 2478 | CRX070 | BILLING-PROV-NUM | Not Applicable | NA | if value is invalid, record it exactly as it appears in the state system. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX070-0003 |
| 2479 | CRX070 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX070-0004 |
| 2480 | CRX070 | BILLING-PROV-NUM | Not Applicable | NA | The value reported in BILLING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX070-0005 |
| 2481 | CRX071 | BILLING-PROV-NPI-NUM | The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care. |
Required | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX071-0001 |
| 2482 | CRX071 | BILLING-PROV-NPI-NUM | Not Applicable | NA | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX071-0002 |
| 2483 | CRX071 | BILLING-PROV-NPI-NUM | Not Applicable | NA | For encounter records (TYPE-OF-CLAIM = 3, C, W), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity billing (or reporting) to the managed care plan. For financial transactions (i.e., expenditure transactions or recoupments of previously made expenditures that do not flow through the usual claim adjudication/adjustment process or encounter record reporting process), the BILLING-PROV-NPI-NUM field should be populated with the NPI of the provider or entity to which the financial transaction was addressed, unless the transaction is a payment/recoupment made-to/received-from a managed care plan, in which case the BILLING-PROV-NPI-NUM should be left blank. For financial transactions with managed care plans, the plan's ID should be reported in the PLAN-ID-NUMBER field and the BILLING-PROV-NPI-NUM should be left blank. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX071-0003 |
| 2484 | CRX071 | BILLING-PROV-NPI-NUM | Not Applicable | NA | Billing Provider must be enrolled | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX071-0004 |
| 2485 | CRX072 | BILLING-PROV-TAXONOMY | For CLAIMOT and CLAIMRX files, the taxonomy code for the provider billing for the service. | Conditional | Value must be in the set of valid values | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX072-0001 |
| 2486 | CRX072 | BILLING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX072-0002 |
| 2487 | CRX073 | BILLING-PROV-SPECIALTY | This code describes the area of specialty for the billing provider. | Conditional | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX073-0001 |
| 2488 | CRX074 | PRESCRIBING-PROV-NUM | A unique identification number assigned by the state to the provider who prescribed the drug, device, or supply. This must be the individual’s ID number, not a group identification number. | Required | Valid formats must be supplied by the state in advance of submitting file data. |
Valid values are supplied by the state. | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX074-0001 |
| 2489 | CRX074 | PRESCRIBING-PROV-NUM | Not Applicable | NA | if value is invalid, record it exactly as it appears in the state system. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX074-0002 |
| 2490 | CRX074 | PRESCRIBING-PROV-NUM | Not Applicable | NA | if the prescribing physician provider ID is not available, but the physician’s Drug Enforcement Agency (DEA) ID is on the state file, then the State should use the DEA ID for this data element | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX074-0003 |
| 2491 | CRX074 | PRESCRIBING-PROV-NUM | Not Applicable | NA | The value reported in PRESCRIBING-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX074-0004 |
| 2492 | CRX074 | PRESCRIBING-PROV-NUM | Not Applicable | NA | The value reported in PRESCRIBING-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX074-0005 |
| 2493 | CRX075 | PRESCRIBING-PROV-NPI-NUM | The National Provider ID (NPI) of the provider who prescribed a medication to a patient | Required | NPI must be valid. If provider does not have an NPI, leave the field blank. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX075-0001 |
| 2494 | CRX075 | PRESCRIBING-PROV-NPI-NUM | Not Applicable | NA | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX075-0002 |
| 2495 | CRX076 | PRESCRIBING-PROV-TAXONOMY | The taxonomy code for the medical provider writing the prescription | NA | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX076-0001 |
| 2496 | CRX076 | PRESCRIBING-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX076-0002 |
| 2497 | CRX077 | PRESCRIBING-PROV-TYPE | A code describing the type of entity prescribing the drug, device, or supply If the state uses state-specific codes, they should map their internal codes to the CMS standard list provided |
NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #3 for a listing of valid values. | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX077-0001 |
| 2498 | CRX078 | PRESCRIBING-PROV-SPECIALTY | This code indicates the area of specialty for the PRESCRIBING PROVIDER. | NA | Value must be equal to a valid value. | See Appendix A under PROV-CLASSIFICATION-CODE #2 for a listing of valid values. | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX078-0001 |
| 2499 | CRX079 | MEDICARE-HIC-NUM | Health Insurance Claim (HIC) Number as it appears on the patient’s Medicare card. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX079-0001 |
| 2500 | CRX079 | MEDICARE-HIC-NUM | Not Applicable | NA | if individual is NOT enrolled in Medicare, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX079-0002 |
| 2501 | CRX079 | MEDICARE-HIC-NUM | Not Applicable | NA | If this is a crossover Medicare claim, the Bene must have a MEDICARE-HIC-Num. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX079-0003 |
| 2502 | CRX079 | MEDICARE-HIC-NUM | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's Medicare HIC Number does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX079-0004 |
| 2503 | CRX079 | MEDICARE-HIC-NUM | Not Applicable | NA | Claims records for an eligible individual should not indicate a valid Medicare HIC number, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX079-0005 |
| 2504 | CRX081 | REMITTANCE-NUM | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX081-0001 |
| 2505 | CRX081 | REMITTANCE-NUM | Not Applicable | NA | If there is a remittance date, then there must also be a remittance number. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX081-0002 |
| 2506 | CRX082 | BORDER-STATE-IND | This code indicates whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX082-0001 |
| 2507 | CRX084 | DATE-PRESCRIBED | The date the drug, device, or supply was prescribed by the physician or other practitioner. This should not be confused with the PRESCRIPTION-FILL-DATE, which represents the date the prescription was actually filled by the provider. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX084-0001 |
| 2508 | CRX084 | DATE-PRESCRIBED | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX084-0002 |
| 2509 | CRX084 | DATE-PRESCRIBED | Not Applicable | NA | Date must occur on or after Date of Birth | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX084-0003 |
| 2510 | CRX084 | DATE-PRESCRIBED | Not Applicable | NA | Date must on or before Prescription Fill Date. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX084-0004 |
| 2511 | CRX084 | DATE-PRESCRIBED | Not Applicable | NA | DATE-PRESCRIBED must occur on or before ADJUDICATION-DATE. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX084-0005 |
| 2512 | CRX084 | DATE-PRESCRIBED | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX084-0006 |
| 2513 | CRX085 | PRESCRIPTION-FILL-DATE | Date the drug, device, or supply was dispensed by the provider. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX085-0001 |
| 2514 | CRX085 | PRESCRIPTION-FILL-DATE | Not Applicable | NA | The date must be a valid date. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX085-0002 |
| 2515 | CRX085 | PRESCRIPTION-FILL-DATE | Not Applicable | NA | PRESCRIPTION-FILL-DATE must occur on or before END-OF-TIME-PERIOD | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX085-0003 |
| 2516 | CRX085 | PRESCRIPTION-FILL-DATE | Not Applicable | NA | PRESCRIPTION-FILL-DATE must occur on or after START-OF-TIME-PERIOD | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX085-0004 |
| 2517 | CRX085 | PRESCRIPTION-FILL-DATE | Not Applicable | NA | PRESCRIPTION-FILL-DATE must occur on or after DATE-PRESCRIBED | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX085-0005 |
| 2518 | CRX085 | PRESCRIPTION-FILL-DATE | Not Applicable | NA | Date must occur on or after Date of Birth | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX085-0006 |
| 2519 | CRX085 | PRESCRIPTION-FILL-DATE | Not Applicable | NA | Date must occur on or before Date of Death. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX085-0007 |
| 2520 | CRX086 | COMPOUND-DRUG-IND | Indicator to specify if the drug is compound or not. | Conditional | Value must be in the set of valid values | 0 Not Compound 1 Compound |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX086-0001 |
| 2521 | CRX087 | BENEFICIARY-COINSURANCE-AMOUNT | The amount of money the beneficiary paid towards coinsurance. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX087-0001 |
| 2522 | CRX087 | BENEFICIARY-COINSURANCE-AMOUNT | Not Applicable | NA | if no coinsurance is applicable enter 0.00. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX087-0002 |
| 2523 | CRX088 | BENEFICIARY-COINSURANCE-DATE-PAID | The date the beneficiary paid the coinsurance amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX088-0001 |
| 2524 | CRX088 | BENEFICIARY-COINSURANCE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX088-0002 |
| 2525 | CRX089 | BENEFICIARY-COPAYMENT-AMOUNT | The amount of money the beneficiary paid towards a copayment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX089-0001 |
| 2526 | CRX089 | BENEFICIARY-COPAYMENT-AMOUNT | Not Applicable | NA | if no copayment is applicable enter 0.00. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX089-0002 |
| 2527 | CRX090 | BENEFICIARY-COPAYMENT-DATE-PAID | The date the beneficiary paid the copayment amount. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX090-0001 |
| 2528 | CRX092 | BENEFICIARY-DEDUCTIBLE-AMOUNT | The amount of money the beneficiary paid towards an annual deductible. |
Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX092-0001 |
| 2529 | CRX092 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Not Applicable | NA | if no deductible is applicable enter 0.00. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX092-0002 |
| 2530 | CRX093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | The date the beneficiary paid the deductible amount. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX093-0001 |
| 2531 | CRX093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX093-0002 |
| 2532 | CRX093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Not Applicable | NA | if no coinsurance is applicable, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX093-0003 |
| 2533 | CRX094 | CLAIM-DENIED-INDICATOR | An indicator to identify a claim that the state refused pay in its entirety. |
Conditional | Value must be in the set of valid values | 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. |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX094-0001 |
| 2534 | CRX094 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | it is expected that states will submit all denied claims to CMS | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX094-0002 |
| 2535 | CRX094 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All denied claims should have CLAIM-DENIED-INDICATOR = 0 AND CLAIM-STATUS-CATEGORY = F2. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX094-0003 |
| 2536 | CRX094 | CLAIM-DENIED-INDICATOR | Not Applicable | NA | All claims with TOC = Z OR CLAIM-STATUS = 26, 87, 542, 858, or 654 should also have CLAIM-DENIED-INDICATOR = 0 and CLAIM-STATUS-CATEGORY = F2 | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable |
| 2537 | CRX095 | COPAY-WAIVED-IND | An indicator signifying that the copay was waived by the provider. |
Optional | Value must be equal to a valid value. | 0 Not Waived: The provider did not waive the beneficiary’s copayment 1 Waived: The provider waived the beneficiary’s copayment |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX095-0001 |
| 2538 | CRX096 | HEALTH-HOME-ENTITY-NAME | A free-form text field to indicate the health home that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A “Health Home Entity” can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities’ names are being used instead. |
Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX096-0001 |
| 2539 | CRX096 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's health home entity name does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX096-0002 |
| 2540 | CRX096 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | States should not submit records for an eligible individual where the eligible's health home entity name does not match in the associated claim record, if applicable. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX096-0003 |
| 2541 | CRX098 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item. |
Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX098-0001 |
| 2542 | CRX099 | THIRD-PARTY-COINSURANCE-DATE-PAID | The date the third party paid the coinsurance amount. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX099-0001 |
| 2543 | CRX099 | THIRD-PARTY-COINSURANCE-DATE-PAID | Not Applicable | NA | The date must be a valid date. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX099-0002 |
| 2544 | CRX100 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | The amount the third party paid the copayment amount. |
Optional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX100-0001 |
| 2545 | CRX101 | THIRD-PARTY-COPAYMENT-DATE-PAID | The date the third party paid the copayment amount. |
Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX101-0001 |
| 2546 | CRX101 | THIRD-PARTY-COPAYMENT-DATE-PAID | Not Applicable | NA | The date must be a valid date. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX101-0002 |
| 2547 | CRX102 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug. | Required | Valid characters include only numbers (0-9) | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX102-0001 |
| 2548 | CRX102 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | Not Applicable | NA | The value must be a valid NPI. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX102-0002 |
| 2549 | CRX103 | DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | The Provider Taxonomy of the provider responsible for dispensing the prescription drug. | NA | Value must be in the set of valid values | http://www.wpc-edi.com/reference/ | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX103-0001 |
| 2550 | CRX103 | DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | Not Applicable | NA | Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX103-0002 |
| 2551 | CRX103 | DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | Not Applicable | NA | Left-fill unused bytes with spaces. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX103-0003 |
| 2552 | CRX104 | HEALTH-HOME-PROVIDER-NPI | The National Provider ID (NPI) of the health home provider. | Conditional | Valid characters include only numbers (0-9) | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX104-0001 |
| 2553 | CRX104 | HEALTH-HOME-PROVIDER-NPI | Not Applicable | NA | The value must be a valid NPI. | https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/ | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX104-0002 |
| 2554 | CRX105 | MEDICARE-BENEFICIARY-IDENTIFIER | The individual’s Medicare Beneficiary Identifier (MBI) Identification Number. Note: MBI replaces the HICN with an entirely new Medicare Beneficiary Identifier (MBI) for purposes of provider billing, if applicable. CMS interfaces with non-payment exchange partners would remain HICN-based, while interfaces with payment partners would use the new MBI. |
NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX105-0001 |
| 2555 | CRX105 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | if individual is NOT enrolled in Medicare, leave blank or space-fill. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX105-0002 |
| 2556 | CRX105 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) until such time as the Medicare Beneficiary Identifier is implemented (no target date has been established). | Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX105-0003 |
| 2557 | CRX106 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX106-0001 |
| 2558 | CRX106 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX106-0002 |
| 2559 | CRX107 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX107-0001 |
| 2560 | CRX108 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the CLAIM-HEADER-RECORD-IP record segment is CIP00002. | Required | Value must be equal to a valid value. | CRX00003 | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX108-0001 |
| 2561 | CRX108 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX108-0002 |
| 2562 | CRX109 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX109-0001 |
| 2563 | CRX109 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX109-0002 |
| 2564 | CRX109 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX109-0003 |
| 2565 | CRX109 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX109-0004 |
| 2566 | CRX110 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX110-0001 |
| 2567 | CRX110 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX110-0002 |
| 2568 | CRX110 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX110-0004 |
| 2569 | CRX111 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS Identification Number must be reported | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX111-0001 |
| 2570 | CRX111 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the state ID numbers must be supplied to CMS. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX111-0002 |
| 2571 | CRX111 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain that number. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX111-0003 |
| 2572 | CRX111 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For TYPE-OF-CLAIM = 4 or D (lump sum adjustments), this field must begin with an ‘&’. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX111-0004 |
| 2573 | CRX112 | ICN-ORIG | A unique number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies an original claim. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX112-0001 |
| 2574 | CRX112 | ICN-ORIG | Not Applicable | NA | Record the value exactly as it appears in the state system. Do not pad. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX112-0002 |
| 2575 | CRX112 | ICN-ORIG | Not Applicable | NA | If using the original ICN approach for reporting adjustment claims, this field should always be populated with the claim identification number assigned to the original paid/denied claim. This identification number should remain constant and be carried forward onto any adjustment claims. The intention is for this earliest claim identification number to be the link that ties the original claim and all adjustment claims together. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX112-0003 |
| 2576 | CRX112 | ICN-ORIG | Not Applicable | NA | If using the daisy-chain ICN approach for reporting adjustment claims, the initial adjustment record will populate this field with the claim identification number assigned to the original paid/denied claim. Subsequent adjustment should populate the ICN-ORIG field with the claim identification number reported in the ICN-ADJ field of the prior adjustment claim. The intention is to use the most recently assigned unique identifier from the prior claim to link the chain of adjustment claims. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable |
| 2577 | CRX113 | ICN-ADJ | A unique claim number (up to 21 alpha/numeric characters) assigned by the state’s payment system that identifies the adjustment claim for an original transaction. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX113-0001 |
| 2578 | CRX113 | ICN-ADJ | Not Applicable | NA | Record the value exactly as it appears in the State system. Do not pad | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX113-0002 |
| 2579 | CRX113 | ICN-ADJ | Not Applicable | NA | This field should be blank-filled if the ADJUSTMENT-INDICATOR = 0 | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX113-0003 |
| 2580 | CRX114 | LINE-NUM-ORIG | A unique number to identify the transaction line number that is being reported on the original claim. | Required | Record the value exactly as it appears in the State system. Do not pad. This field should also be completed on adjustment claims to reflect the LINE-NUMBER of the INTERNAL-CONTROL-NUMBER on the claim that is being adjusted. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX114-0001 |
| 2581 | CRX115 | LINE-NUM-ADJ | A unique number to identify the transaction line number that identifies the line number on the adjustment ICN. | Conditional | Record the value exactly as it appears in the state system. Do not pad. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX115-0001 |
| 2582 | CRX115 | LINE-NUM-ADJ | Not Applicable | NA | This field should be 8-filled, left blank or space-filled if the ADJUSTMENT-INDICATOR = 0. Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX115-0002 |
| 2583 | CRX116 | LINE-ADJUSTMENT-IND | Code indicating type of adjustment record claim/encounter represents at claim detail level. | Conditional | Value must be equal to a valid value. | 0 Original Claim / Encounter 1 Void / Reversal of a prior submission 4 Replacement / Resubmission of a prior submission 5 Gross Credit / Gross Credit Adjustment 6 Gross Debit / Debit Credit Adjustment |
8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX116-0001 |
| 2584 | CRX116 | LINE-ADJUSTMENT-IND | Not Applicable | NA | If there is a line adjustment number, then there must be a line-adjustment indicator. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX116-0002 |
| 2585 | CRX116 | LINE-ADJUSTMENT-IND | Not Applicable | NA | Value must be equal to a valid value. ADJUSTMENT-IND values of "0", "1", "4" should be reported when TYPE-OF-CLAIM = "1", "3", "5", "A", "C", "E", "U", "W", "Y". ADJUSTMENT-IND values of "5" or "6" should be reported when TYPE-OF-CLAIM = "4", "D" or "X" |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX116-0004 |
| 2586 | CRX117 | LINE-ADJUSTMENT-REASON-CODE | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/ | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX117-0001 |
| 2587 | CRX117 | LINE-ADJUSTMENT-REASON-CODE | Not Applicable | NA | If there is no adjustment to a line, then there is no adjustment reason code. (Also see: CLAIM-PYMT-REM-CODE) | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX117-0002 |
| 2588 | CRX118 | SUBMITTER-ID | The Submitter ID number is the value that identifies the provider/trading partner/clearing house organization to state’s claim adjudication system. | Required | Value must not be null | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX118-0001 |
| 2589 | CRX119 | CLAIM-LINE-STATUS | The claim line status codes identify the status of a specific detail claim line rather than the entire claim. | Conditional | Value must be equal to a valid value. | http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX119-0001 |
| 2590 | CRX120 | NATIONAL-DRUG-CODE | A code in National Drug Code (NDC) format indicating the drug, device, or medical supply covered by this claim. | Required | Position 10-11 must be Alpha Numeric or blank | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX120-0001 |
| 2591 | CRX120 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 1-5 must be Numeric | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX120-0002 |
| 2592 | CRX120 | NATIONAL-DRUG-CODE | Not Applicable | NA | Position 6-9 must be Alpha Numeric | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX120-0003 |
| 2593 | CRX120 | NATIONAL-DRUG-CODE | Not Applicable | NA | Drug code formats must be supplied by State in advance of submitting any file data. States must inform CMS of the NDC segments used and their size (e.g., {5, 4, 2} or {5, 4} as defined in the National Drug Code Directory). | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX120-0004 |
| 2594 | CRX120 | NATIONAL-DRUG-CODE | Not Applicable | NA | If the Drug Code is less than 11 characters in length, the value must be left justified and padded with spaces. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX120-0005 |
| 2595 | CRX120 | NATIONAL-DRUG-CODE | Not Applicable | NA | If Durable Medical Equipment or supply is prescribed by a physician and provided by a pharmacy then HCPCS or state specific codes can be put in the NDC field. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX120-0006 |
| 2596 | CRX120 | NATIONAL-DRUG-CODE | Not Applicable | NA | This field is applicable only for TYPE-OF-SERVICE = 035, 036, 077, 062, 063, 064, 065, 066, 067, 068, 069, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083, 084, 033, 034. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX120-0007 |
| 2597 | CRX121 | BILLED-AMT | The amount billed at the claim detail level as submitted by the provider. |
Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX121-0001 |
| 2598 | CRX121 | BILLED-AMT | Not Applicable | NA | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed the managed care plan. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX121-0002 |
| 2599 | CRX122 | ALLOWED-AMT | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX122-0001 |
| 2600 | CRX123 | COPAY-AMT | The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX123-0001 |
| 2601 | CRX124 | TPL-AMT | Third Party Liability (TPL) refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX124-0001 |
| 2602 | CRX125 | MEDICAID-PAID-AMT | The amount paid by Medicaid/CHIP or the managed care organization on this claim or adjustment at the claim detail level. | Required | If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX125-0001 |
| 2603 | CRX125 | MEDICAID-PAID-AMT | Not Applicable | NA | For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX125-0002 |
| 2604 | CRX125 | MEDICAID-PAID-AMT | Not Applicable | NA | For Crossover claims with Medicare Coinsurance and/or Deductibles, enter the sum of those amounts in the Medicaid-Amount-Paid field, if the providers were reimbursed by Medicaid for them. If the Coinsurance and Deductibles were not paid by the state, then report the Medicaid-Amount-Paid as $0. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX125-0003 |
| 2605 | CRX125 | MEDICAID-PAID-AMT | Not Applicable | NA | If TYPE‐OF‐CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the managed care plan paid to the provider. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX125-0004 |
| 2606 | CRX126 | MEDICAID-FFS-EQUIVALENT-AMT | The MEDICAID-FFS-EQUIVALENT-AMT field should be populated with the amount that would have been paid had the services been provided on a FFS basis. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX126-0001 |
| 2607 | CRX126 | MEDICAID-FFS-EQUIVALENT-AMT | Not Applicable | NA | Required when TYPE-OF-CLAIM = C, 3, or W | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX126-0002 |
| 2608 | CRX127 | MEDICARE-DEDUCTIBLE-AMT | The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary’s Medicare deductible. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX127-0001 |
| 2609 | CRX127 | MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | If claim is not a Crossover claim, or if a TYPE-OF-CLAIM = 3, C, W (encounter claim), leave blank or space-fill | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX127-0002 |
| 2610 | CRX127 | MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount and code space in MEDICARE-COINSURANCE-PAYMENT. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX127-0003 |
| 2611 | CRX127 | MEDICARE-DEDUCTIBLE-AMT | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any deductible amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX127-0004 |
| 2612 | CRX128 | MEDICARE-COINS-AMT | The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX128-0001 |
| 2613 | CRX128 | MEDICARE-COINS-AMT | Not Applicable | NA | Value must be 8-filled, left blank or space-filled if 'MEDICARE-DEDUCTIBLE-AMT' is 8-filled, blank or space-filled. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable |
| 2614 | CRX128 | MEDICARE-COINS-AMT | Not Applicable | NA | If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, fill this field with 99998 and code the combined payment amount in MEDICARE-DEDUCTIBLE-AMT. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX128-0002 |
| 2615 | CRX129 | MEDICARE-PAID-AMT | The amount paid by Medicare on this claim or adjustment. | Required | This data element must include a valid dollar amount. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX129-0001 |
| 2616 | CRX129 | MEDICARE-PAID-AMT | Not Applicable | NA | If the service was covered by Medicare but Medicare had no liability for the bill, zero-fill. MEDICARE-PAID-AMT should reflect the actual amount paid by Medicare. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX129-0002 |
| 2617 | CRX129 | MEDICARE-PAID-AMT | Not Applicable | NA | For claims where Medicare payment is only available at the header level, report the entire payment amount the T-MSIS record corresponding to the line item with the highest charge. Zero fill Medicare Amount Paid on all other T-MSIS records created from the original claim. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX129-0003 |
| 2618 | CRX129 | MEDICARE-PAID-AMT | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX129-0004 |
| 2619 | CRX131 | OT-RX-CLAIM-QUANTITY-ALLOWED | The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. | Conditional | Must be numeric | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX131-0001 |
| 2620 | CRX131 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX131-0002 |
| 2621 | CRX131 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX131-0003 |
| 2622 | CRX131 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX131-0004 |
| 2623 | CRX131 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | Left-fill field with zeros if value is less than 9 bytes long. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX131-0005 |
| 2624 | CRX131 | OT-RX-CLAIM-QUANTITY-ALLOWED | Not Applicable | NA | For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX131-0006 |
| 2625 | CRX132 | OT-RX-CLAIM-QUANTITY-ACTUAL | The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span. |
Required | Must be numeric | Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX132-0001 |
| 2626 | CRX132 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. |
Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX132-0002 |
| 2627 | CRX132 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | NOTE: One prescription for 100 250 milligram tablets results in QUANTITY OF SERVICE=100. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX132-0003 |
| 2628 | CRX132 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | The value in OT-RX-CLAIM-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX132-0004 |
| 2629 | CRX132 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | Left-fill field with zeros if value is less than 9 bytes long. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX132-0005 |
| 2630 | CRX132 | OT-RX-CLAIM-QUANTITY-ACTUAL | Not Applicable | NA | For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX132-0006 |
| 2631 | CRX133 | UNIT-OF-MEASURE | A code to indicate the basis by which the quantity of the drug or supply is expressed. |
Conditional | Value must be equal to a valid value. | F2 International Unit ML Milliliter GR Gram ME Milligram UN Unit |
8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX133-0001 |
| 2632 | CRX133 | UNIT-OF-MEASURE | Not Applicable | NA | Enter the unit of measure for each corresponding quantity value. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX133-0002 |
| 2633 | CRX134 | TYPE-OF-SERVICE | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX134-0001 |
| 2634 | CRX134 | TYPE-OF-SERVICE | Not Applicable | NA | Pharmacy Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE= 011, 018, 033, 034, 036, 085, 089, 127, or 131. | Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX134-0002 |
| 2635 | CRX134 | TYPE-OF-SERVICE | Not Applicable | NA | Experience has demonstrated there can be instances when more than one service area category could be applicable for a provided service. The following hierarchy rules apply to these instances: o The specific service categories of sterilizations and other pregnancy-related procedures take precedence over provider categories, such as inpatient hospital or outpatient hospital. o Services of a physician employed by a clinic are reported under clinic services if the clinic is the billing entity. X-rays processed by the clinic in the course of treatment, however, are reported under X-ray services. o Services of a registered nurse attending a resident in a NF are reported (if they qualified under the coverage rules) under home health services if they were not billed as part of the NF bill. |
Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX134-0003 |
| 2636 | CRX134 | TYPE-OF-SERVICE | Not Applicable | NA | See Appendix D for information on the various types of service. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX134-0004 |
| 2637 | CRX134 | TYPE-OF-SERVICE | Not Applicable | NA | All claims for inpatient psychiatric care provided in a separately administered psychiatric wing or psychiatric hospital are included in the CLAIMLT file. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX134-0005 |
| 2638 | CRX135 | HCBS-SERVICE-CODE | Codes indicating that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes are to help clearly delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services). | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX135-0001 |
| 2639 | CRX136 | HCBS-TAXONOMY | A code that classifies home and community based services listed on the claim into the HCBS taxonomy. |
Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX136-0001 |
| 2640 | CRX136 | HCBS-TAXONOMY | Not Applicable | NA | If HCBS-SERVICE-CODE = 1 through 8, then populate HCBS-TAXONOMY with one of the values from the list in Appendix B. | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX136-0002 |
| 2641 | CRX136 | HCBS-TAXONOMY | Not Applicable | NA | If HCBS-SERVICE-CODE = 9 (It is unknown what authority the HCBS service was provided), then populate HCBS-TAXONOMY based on the assumption that the services is not a 1915(j), 1915(k), 1915(c) waiver, or 1115 waiver service. (See “If HCBS-SERVICE-CODE = 1 through 8” above.) | Not Applicable | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX136-0003 |
| 2642 | CRX137 | OTHER-TPL-COLLECTION | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX137-0001 |
| 2643 | CRX138 | DAYS-SUPPLY | Number of days supply dispensed. | Required | Values should be between -365 and 365. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX138-0001 |
| 2644 | CRX138 | DAYS-SUPPLY | Not Applicable | NA | For Prescription Drugs, value should be between -365 and 365. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX138-0002 |
| 2645 | CRX139 | NEW-REFILL-IND | Indicator showing whether the prescription being filled was a new prescription or a refill. If it is a refill, the indicator will indicate the number of refills. | Required | Value must be equal to a valid value. | 00 New Prescription 01-98 Number of Refill(s) |
8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX139-0001 |
| 2646 | CRX140 | BRAND-GENERIC-IND | Indicates whether the drug is a brand name, generic, single-source, or multi-source drug. | Required | Value must be in the set of valid values | 0 Non-Drug 1 Generic 2 Brand 3 Multi-Source 4 Single-Source |
4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX140-0001 |
| 2647 | CRX141 | DISPENSE-FEE | The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription. | Required | This data element must include a valid dollar amount. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX141-0001 |
| 2648 | CRX142 | PRESCRIPTION-NUM | The unique identification number assigned by the pharmacy or supplier to the prescription | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX142-0001 |
| 2649 | CRX143 | DRUG-UTILIZATION-CODE | A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS DRUG-UTILIZATION-CODE data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (44Ø-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Results of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS DRUG-UTILIZATION-CODE) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS DRUG-UTILIZATION-CODE) describes the action the pharmacist took in response to a conflict or the result of a pharmacist’s professional service. Because the T-MSIS DRUG-UTILIZATION-CODE data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes. |
Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX143-0001 |
| 2650 | CRX144 | DTL-METRIC-DEC-QTY | Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter). | Required | Must be numeric | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX144-0001 |
| 2651 | CRX145 | COMPOUND-DOSAGE-FORM | The physical form of a dose of medication, such as a capsule or injection. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX145-0001 |
| 2652 | CRX146 | REBATE-ELIGIBLE-INDICATOR | An indicator to identify claim lines with an NDC that is eligible for the drug rebate program. | Conditional | Value must be equal to a valid value. | 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) |
8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX146-0001 |
| 2653 | CRX147 | IMMUNIZATION-TYPE | This field identifies the type of immunization provided in order to track additional detail not currently contained in CPT codes. | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX147-0001 |
| 2654 | CRX148 | BENEFIT-TYPE | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System’s (MACPro’s) benefit type list. See Appendix H: Benefit Types for descriptions of the categories. |
Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 2/25/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX148-0001 |
| 2655 | CRX149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | This code indicates if the claim was matched with Title XIX or Title XXI. |
Required | Value must be equal to a valid value. | 01 Federal funding under Title XIX 02 Federal funding under Title XXI 03 Federal funding under ACA 04 Federal funding under other legislation |
4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX149-0001 |
| 2656 | CRX149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX149-0002 |
| 2657 | CRX149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Not Applicable | NA | If an individual is not eligible for Medicaid, then any associated claims records should not have reimbursed with federal funding under Title XIX. | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX149-0003 |
| 2658 | CRX150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation |
Conditional | Value must be equal to a valid value. | See Appendix I for listing of valid values. | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX150-0001 |
| 2659 | CRX150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | Not Applicable | NA | Males cannot receive services where the category of service is "Other Pregnancy-related Procedures", "Nurse Mid-wife", "Freestanding Birth Center" or "Tobacco Cessation for Pregnant Women". | Not Applicable | 4/30/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX150-0002 |
| 2660 | CRX151 | XXI-MBESCBES-CATEGORY-OF-SERVICE | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. Refer to Attachment 8 for definitions on the various categories of service. | Conditional | Value must be equal to a valid value. | See Appendix J for listing of valid values. | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX151-0001 |
| 2661 | CRX152 | OTHER-INSURANCE-AMT | The amount paid by insurance other than Medicare or Medicaid on this claim. | Conditional | This data element must include a valid dollar amount. | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX152-0001 |
| 2662 | CRX153 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX153-0001 |
| 2663 | CRX153 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” a single 8, or 8-fill the field when not using the field to record specific comments. For fixed-length files, states should 8-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX153-0002 |
| 2664 | CRX154 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX154-0001 |
| 2665 | CRX155 | SEQUENCE-NUMBER | To enable state’s to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' SUBMISSION-TRANSACTION-TYPE record files. | Not Applicable | 8/7/2017 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX155-0001 |
| 2666 | CRX155 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | CRX155-0002 |
| 2667 | CRX156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | The state-specific provider id of the provider who actually dispensed the prescription medication. | Required | Valid formats must be supplied by the state in advance of submitting file data. |
Valid values are supplied by the state. | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX156-0001 |
| 2668 | CRX156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Not Applicable | NA | If value is invalid, record it exactly as it appears in the state system. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX156-0002 |
| 2669 | CRX156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Not Applicable | NA | Note: Once a national provider ID numbering system is in place, the national number should be used. If the state’s legacy ID number is only available, then that number can be entered in this field. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX156-0003 |
| 2670 | CRX156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Not Applicable | NA | The value reported in DISPENSING-PRESCRIPTION-DRUG-PROV-NUM should match a value in the PROV-IDENTIFIER field in which PROV-IDENTIFIER-TYPE = "1" on the same record in the Provider file. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX156-0004 |
| 2671 | CRX156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Not Applicable | NA | The value reported in DISPENSING-PRESCRIPTION-DRUG-PROV-NUM should match a value reported in the SUBMITTING-STATE-PROV-ID on the provider file. | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX156-0005 |
| 2672 | CRX157 | ADJUDICATION-DATE | The date on which the payment status of the claim was finally adjudicated by the state. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0001 |
| 2673 | CRX157 | ADJUDICATION-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0002 |
| 2674 | CRX157 | ADJUDICATION-DATE | Not Applicable | NA | For Encounter Records (TYPE-OF-CLAIM=3, C, W); use date the encounter was processed by the state. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0003 |
| 2675 | CRX157 | ADJUDICATION-DATE | Not Applicable | NA | For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0004 |
| 2676 | CRX157 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or before END-OF-TIME-PERIOD included in the T-MSIS HEADER RECORD | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0005 |
| 2677 | CRX157 | ADJUDICATION-DATE | Not Applicable | NA | ADJUDICATION-DATE should occur on or after the ADMISSION-DATE | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0006 |
| 2678 | CRX157 | ADJUDICATION-DATE | Not Applicable | NA | This date must occur on or after the DATE-OF-BIRTH in the Eligible Record when the eligible is not a CHIP unborn child. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0007 |
| 2679 | CRX157 | ADJUDICATION-DATE | Not Applicable | NA | A Medicaid or CHIP eligible individual should not have had a claim adjudicated before their five-year immigration ineligible status has expired, except when the eligible is an unborn child in the CHIP program. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX157-0008 |
| 2680 | CRX158 | SELF-DIRECTION-TYPE | This data element is not applicable to this file type. | Conditional | Value must be equal to a valid value. | 000 Not Applicable 001 Hiring Authority 002 Budget Authority 003 Hiring and Budget Authority |
8/7/2017 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX158-0001 |
| 2681 | CRX159 | PRE-AUTHORIZATION-NUM | A number, code, or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also called Prior Authorization or Referral Number) | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | CRX159-0001 |
| 2682 | CRX160 | MEDICARE-COMB-DED-IND | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated | Conditional | Value must be equal to a valid value. | 0 Amount not combined with coinsurance amount 1 Amount combined with coinsurance amount |
8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX160-0001 |
| 2683 | CRX160 | MEDICARE-COMB-DED-IND | Not Applicable | NA | Claims records for an eligible individual should not indicate Medicare paid any combined deductible amount on the claim, if the eligible individual is not a dual eligible. | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX160-0003 |
| 2684 | CRX161 | PROV-LOCATION-ID | A code to uniquely identify the geographic location where the provider’s services were performed. The value should correspond to an active value in the PROV-LOCATION-ID field in the provider subject area. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX161-0001 |
| 2685 | CRX161 | PROV-LOCATION-ID | Not Applicable | NA | The value should correspond with one of the location identifiers recorded in the provider’s demographic records in the T-MSIS data set. If a particular license is applicable to all locations, create an identifier that signifies "All Locations" | Not Applicable | 8/7/2017 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | CRX161-0002 |
| 2686 | ELG001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00001 | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG001-0002 |
| 2687 | ELG001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG001-0001 |
| 2688 | ELG002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG002-0001 |
| 2689 | ELG003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG003-0001 |
| 2690 | ELG003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable |
| 2691 | ELG004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or delimited format. | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG004-0001 |
| 2692 | ELG005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document | Not Applicable | 2/25/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG005-0001 |
| 2693 | ELG006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Required on every file header | Not Applicable | 2/25/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG006-0001 |
| 2694 | ELG006 | FILE-NAME | Not Applicable | NA | Value must be equal to a valid value. | ELIGIBLE - Eligible file | 2/25/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG006-0002 |
| 2695 | ELG006 | FILE-NAME | Not Applicable | NA | The file name must exist in the File Label Internal Dataset Name. | Not Applicable | 10/10/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG006-0003 |
| 2696 | ELG007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG007-0002 |
| 2697 | ELG007 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG007-0001 |
| 2698 | ELG007 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable |
| 2699 | ELG007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG007-0003 |
| 2700 | ELG008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 2/25/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG008-0001 |
| 2701 | ELG008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG008-0002 |
| 2702 | ELG008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field. | Not Applicable | 2/25/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG008-0003 |
| 2703 | ELG008 | DATE-FILE-CREATED | Not Applicable | NA | Required on every file header | Not Applicable | 4/30/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG008-0004 |
| 2704 | ELG009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG009-0001 |
| 2705 | ELG009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable |
| 2706 | ELG009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable |
| 2707 | ELG009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG009-0003 |
| 2708 | ELG009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG009-0004 |
| 2709 | ELG009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG009-0005 |
| 2710 | ELG010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. | Required | Value must be a valid date | Not Applicable | 2/25/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG010-0001 |
| 2711 | ELG010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 4/30/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG010-0002 |
| 2712 | ELG010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 10/10/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG010-0003 |
| 2713 | ELG010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than DATE-FILE-CREATED. | Not Applicable | 4/30/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG010-0004 |
| 2714 | ELG010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be greater than START-OF-TIME-PERIOD | Not Applicable | 4/30/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG010-0005 |
| 2715 | ELG010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG010-0006 |
| 2716 | ELG011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG011-0001 |
| 2717 | ELG011 | FILE-STATUS-INDICATOR | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable |
| 2718 | ELG011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 4/30/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG011-0002 |
| 2719 | ELG012 | SSN-INDICATOR | Indicates whether the state uses the eligible person's social security number (SSN) instead of an MSIS identification number as the unique, unchanging eligible person identifier. | Required | Value must be equal to a valid value. | 0 State does not use SSN as MSIS-IDENTIFICATION-NUMBER 1 State uses SSN as MSIS-IDENTIFICATION-NUMBER |
8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG012-0005 |
| 2720 | ELG012 | SSN-INDICATOR | Not Applicable | NA | A state's SSN/Non-SSN designation on the eligibility file should match on the claims and TPL files. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable |
| 2721 | ELG012 | SSN-INDICATOR | Not Applicable | NA | SSN states must report the SSN in both the SSN and MSIS-IDENTIFICATION-NUM fields and set the SSN-INDICATOR to 1. In instances where the social security number is not known and a temporary MSIS identification number is used, SSN states should still set the SSN-INDICATOR to 1. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG012-0003 |
| 2722 | ELG012 | SSN-INDICATOR | Not Applicable | NA | For non-SSN states, the SSN-INDICATOR in the Header record must be set to 0 and the MSIS identification number must be reported in the MSIS-IDENTIFICATION-NUMBER field. If the MSIS-IDENTIFICATION-NUMBER is not known then this field should be left blank or space-filled. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG012-0001 |
| 2723 | ELG013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG013-0001 |
| 2724 | ELG013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG013-0002 |
| 2725 | ELG014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG014-0001 |
| 2726 | ELG014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG014-0002 |
| 2727 | ELG015 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG015-0001 |
| 2728 | ELG016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00002 | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG016-0001 |
| 2729 | ELG016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG016-0003 |
| 2730 | ELG017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG017-0002 |
| 2731 | ELG017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG017-0001 |
| 2732 | ELG017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2733 | ELG017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG017-0003 |
| 2734 | ELG018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG018-0001 |
| 2735 | ELG018 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG018-0002 |
| 2736 | ELG018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG018-0005 |
| 2737 | ELG019 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG019-0001 |
| 2738 | ELG019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG019-0002 |
| 2739 | ELG019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG019-0003 |
| 2740 | ELG019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG019-0004 |
| 2741 | ELG019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2742 | ELG019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG019-0005 |
| 2743 | ELG019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG019-0006 |
| 2744 | ELG020 | ELIGIBLE-FIRST-NAME | The first name of the individual to whom the services were provided. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG020-0001 |
| 2745 | ELG021 | ELIGIBLE-LAST-NAME | The last name of the individual to whom the services were provided. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG021-0001 |
| 2746 | ELG022 | ELIGIBLE-MIDDLE-INIT | The middle initial of the individual to whom the services were provided. | Conditional | Leave blank if not available | Not Applicable | 11/3/2015 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG022-0001 |
| 2747 | ELG022 | ELIGIBLE-MIDDLE-INIT | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG022-0002 |
| 2748 | ELG023 | SEX | The individual’s biological sex. | Required | Value must be equal to a valid value. | F Female M Male U Unknown |
4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG023-0001 |
| 2749 | ELG023 | SEX | Not Applicable | NA | If an eligible individual is a male, he cannot be pregnant (PREGNANCY-IND must = "0"). | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG023-0002 |
| 2750 | ELG024 | DATE-OF-BIRTH | Individual’s date of birth. | Required | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG024-0001 |
| 2751 | ELG024 | DATE-OF-BIRTH | Not Applicable | NA | Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or equal to the pregnant mother's date of birth | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG024-0002 |
| 2752 | ELG024 | DATE-OF-BIRTH | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG024-0003 |
| 2753 | ELG024 | DATE-OF-BIRTH | Not Applicable | NA | The date must be a valid date, unless a complete valid date is not available. | Not Applicable | 4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG024-0004 |
| 2754 | ELG024 | DATE-OF-BIRTH | Not Applicable | NA | An eligible individual's date of birth should not be after his/her date of death. | Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG024-0005 |
| 2755 | ELG024 | DATE-OF-BIRTH | Not Applicable | NA | An eligible individual's date of birth should be on or before the end of time period for the submission. Revise Edit Definition: DATE-OF-BIRTH must be <= END-OF-TIME-PERIOD |
Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG024-0006 |
| 2756 | ELG024 | DATE-OF-BIRTH | Not Applicable | NA | An eligible individual's date of birth should be on or before the date the file was created. | Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG024-0007 |
| 2757 | ELG025 | DATE-OF-DEATH | Individual's date of death. | Conditional | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 11/3/2015 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0001 |
| 2758 | ELG025 | DATE-OF-DEATH | Not Applicable | NA | If individual is not deceased, leave blank or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0002 |
| 2759 | ELG025 | DATE-OF-DEATH | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0003 |
| 2760 | ELG025 | DATE-OF-DEATH | Not Applicable | NA | The date must be a valid date, unless a complete valid date is not available or the eligible individual is not deceased. | Not Applicable | 4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0004 |
| 2761 | ELG025 | DATE-OF-DEATH | Not Applicable | NA | The eligible individual's date of death cannot occur earlier than his/her date of birth. | Not Applicable | 4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0005 |
| 2762 | ELG025 | DATE-OF-DEATH | Not Applicable | NA | The eligible individual's date of death cannot indicate that an eligible individual was greater than 125 years old at the time of death. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0006 |
| 2763 | ELG025 | DATE-OF-DEATH | Not Applicable | NA | Value cannot be > DATE-FILE-CREATED in Header Record | Not Applicable | 4/30/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0007 |
| 2764 | ELG025 | DATE-OF-DEATH | Not Applicable | NA | For records for an eligible individual across time periods, the eligible individual's Date of Death should not vary. | Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG025-0008 |
| 2765 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | The first day of the time span during which the values in all data elements in the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG026-0001 |
| 2766 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2767 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown, leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2768 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG026-0002 |
| 2769 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PRIMARY-DEMOGRAPHICS record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG026-0003 |
| 2770 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | The PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE must occur on or before the PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG026-0004 |
| 2771 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2772 | ELG026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG026-0005 |
| 2773 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | The last day of the time span during which the values in all data elements in the PRIMARY DEMOGRAPHICS– ELIGIBILITY record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG027-0001 |
| 2774 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2775 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2776 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG027-0002 |
| 2777 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG027-0003 |
| 2778 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PRIMARY DEMOGRAPHICS– ELIGIBILITY record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG027-0004 |
| 2779 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable |
| 2780 | ELG027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | The PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE must occur on or after the PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG027-0005 |
| 2781 | ELG028 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG028-0001 |
| 2782 | ELG028 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG028-0002 |
| 2783 | ELG029 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | ELG029-0001 |
| 2784 | ELG030 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00003 | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG030-0001 |
| 2785 | ELG030 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG030-0003 |
| 2786 | ELG031 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG031-0002 |
| 2787 | ELG031 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG031-0001 |
| 2788 | ELG031 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2789 | ELG031 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG031-0003 |
| 2790 | ELG032 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG032-0001 |
| 2791 | ELG032 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG032-0002 |
| 2792 | ELG032 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG032-0003 |
| 2793 | ELG033 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG033-0001 |
| 2794 | ELG033 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG033-0002 |
| 2795 | ELG033 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG033-0003 |
| 2796 | ELG033 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG033-0004 |
| 2797 | ELG033 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2798 | ELG033 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2799 | ELG033 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG033-0005 |
| 2800 | ELG034 | MARITAL-STATUS | A code to classify eligible individual’s marital/domestic-relationship status. | Required | This element should be reported by the state when the information is material to eligibility (i.e., institutionalization). | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG034-0001 |
| 2801 | ELG034 | MARITAL-STATUS | Not Applicable | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG034-0002 |
| 2802 | ELG034 | MARITAL-STATUS | Not Applicable | NA | An eligible individual who is younger than 12 years should have a marital status of never married or unknown. | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG034-0003 |
| 2803 | ELG035 | MARITAL-STATUS-OTHER-EXPLANATION | A free-text field to capture the description of the marital/domestic-relationship status when MARITAL-STATUS=14 (Other) is selected. | Conditional | Conditional; required when MARITAL-STATUS = “14" (Other) | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG035-0001 |
| 2804 | ELG035 | MARITAL-STATUS-OTHER-EXPLANATION | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG035-0002 |
| 2805 | ELG036 | SSN | The eligible individual's social security number. | Required | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG036-0001 |
| 2806 | ELG036 | SSN | Not Applicable | NA | If known, this field is to be populated with numeric digits. | Not Applicable | 4/30/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG036-0002 |
| 2807 | ELG036 | SSN | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG036-0003 |
| 2808 | ELG036 | SSN | Not Applicable | NA | All states must provide available SSNs on the ELIGIBLE FILE, regardless of the use of this field as the unique MSIS-IDENTIFICATION-NUM. |
Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG036-0004 |
| 2809 | ELG036 | SSN | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2810 | ELG036 | SSN | Not Applicable | NA | SSN should not vary across time periods for an eligible individual. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG036-0005 |
| 2811 | ELG036 | SSN | Not Applicable | NA | For SSN states, if the SSN is not available and a temporary identification number has been assigned in the MSIS-IDENTIFICATION-NUMBER field, the SSN field must be blank-filled. |
Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG036-0006 |
| 2812 | ELG037 | SSN-VERIFICATION-FLAG | A code describing whether the state has verified the social security number (SSN) with the Social Security Administration (SSA). | Required | Value must be equal to a valid value. | 0 SSN not verified 1 SSN successfully verified by SSA 2 SSN is pending SSA verification |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG037-0001 |
| 2813 | ELG038 | INCOME-CODE | A code indicating the family income level. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG038-0001 |
| 2814 | ELG039 | VETERAN-IND | A flag indicating if the individual served in the active military, naval, or air service. | Required | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG039-0001 |
| 2815 | ELG039 | VETERAN-IND | Not Applicable | NA | An eligible individual who is younger than 17 years should not be a veteran. | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG039-0002 |
| 2816 | ELG040 | CITIZENSHIP-IND | Indicates if the individual is identified as a U.S. Citizen. | Required | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG040-0001 |
| 2817 | ELG040 | CITIZENSHIP-IND | Not Applicable | NA | All eligible individuals flagged as non-citizens with CITIZENSHIP-IND = "0" should also be flagged as non-citizens with IMMIGRATION-STATUS = "1", "2", or "3" | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG040-0002 |
| 2818 | ELG040 | CITIZENSHIP-IND | Not Applicable | NA | All eligible individuals flagged as U.S. citizens with CITIZENSHIP-IND = "1" should also be flagged as citizens with IMMIGRATION-STATUS = "8" | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2819 | ELG041 | CITIZENSHIP-VERIFICATION-FLAG | Indicates the individual is enrolled in Medicaid pending citizenship verification. | Required | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG041-0001 |
| 2820 | ELG042 | IMMIGRATION-STATUS | The immigration status of the individual. | Required | Value must be equal to a valid value. | 1 Qualified non-citizen 2 Lawfully present under CHIPRA 214 3 Eligible only for payment for emergency services 8 U.S. citizen |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG042-0001 |
| 2821 | ELG042 | IMMIGRATION-STATUS | Not Applicable | NA | All eligible individuals flagged as non-citizens with CITIZENSHIP-IND = "0" should also be flagged as non-citizens with IMMIGRATION-STATUS = "1", "2", or "3" | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG042-0002 |
| 2822 | ELG042 | IMMIGRATION-STATUS | Not Applicable | NA | All eligible individuals flagged as U.S. citizens with CITIZENSHIP-IND = "1" should also be flagged as citizens with IMMIGRATION-STATUS = "8" | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2823 | ELG043 | IMMIGRATION-VERIFICATION-FLAG | Indicates the individual is enrolled in Medicaid pending immigration verification. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG043-0001 |
| 2824 | ELG044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children’s Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a “qualified alien.” |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG044-0001 |
| 2825 | ELG044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Not Applicable | NA | If not applicable (U.S. Citizen), 8-fill, space fill, or blank | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG044-0002 |
| 2826 | ELG044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Not Applicable | NA | If the individual is not a U.S. citizen, then his/her Immigration Status Five Year Bar End Date cannot be designated as not applicable (8-filled, left blank, or space-filled) | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG044-0003 |
| 2827 | ELG044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG044-0004 |
| 2828 | ELG044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG044-0005 |
| 2829 | ELG045 | PRIMARY-LANGUAGE-ENGL-PROF-CODE | A code indicating the level of spoken English proficiency by the individual | Conditional | Value must be equal to a valid value. | 0 Very Well 1 Well 2 Not well 3 No spoken proficiency |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG045-0001 |
| 2830 | ELG045 | PRIMARY-LANGUAGE-ENGL-PROF-CODE | Not Applicable | NA | Report this information for individuals 5 years old or older | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG045-0002 |
| 2831 | ELG046 | PRIMARY-LANGUAGE-CODE | A code indicating the language the individual speaks other than English at home | Conditional | Value must be equal to a valid value. | See language codes in Appendix G for a list of all valid language codes | 11/3/2015 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG046-0001 |
| 2832 | ELG046 | PRIMARY-LANGUAGE-CODE | Not Applicable | NA | See language codes in Appendix G for a list of all valid language codes | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG046-0002 |
| 2833 | ELG046 | PRIMARY-LANGUAGE-CODE | Not Applicable | NA | Report this information for individuals 5 years old or older | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG046-0003 |
| 2834 | ELG047 | HOUSEHOLD-SIZE | Household Size used in the Medicaid or CHIP eligibility determination process | Required | Value must be equal to a valid value. | 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 |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG047-0001 |
| 2835 | ELG047 | HOUSEHOLD-SIZE | Not Applicable | NA | Use this code to indicate Household Size used in the eligibility determination process | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG047-0002 |
| 2836 | ELG049 | PREGNANCY-IND | A flag indicating the individual is pregnant | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG049-0001 |
| 2837 | ELG049 | PREGNANCY-IND | Not Applicable | NA | If an eligible individual is pregnant, she must be a female. | Not Applicable | 4/30/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG049-0002 |
| 2838 | ELG050 | MEDICARE-HIC-NUM | Health Insurance Claim (HIC) Number as it appears on the patient’s Medicare card. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG050-0001 |
| 2839 | ELG050 | MEDICARE-HIC-NUM | Not Applicable | NA | If an eligible individual is enrolled in Medicare (DUAL-ELIGIBLE-CODE = "01", "02", "03", "04", "05", "06", "08", "09", or "10"), MEDICARE-HIC-NUMBER must be reported. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2840 | ELG051 | MEDICARE-BENEFICIARY-IDENTIFIER | The individual’s Medicare Beneficiary Identifier (MBI) Identification Number. Note: MBI replaces the HICN with an entirely new Medicare Beneficiary Identifier (MBI) for purposes of provider billing, if applicable. CMS interfaces with non-payment exchange partners would remain HICN-based, while interfaces with payment partners would use the new MBI. |
NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG051-0001 |
| 2841 | ELG051 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | if individual is NOT enrolled in Medicare, leave blank or space-fill. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG051-0002 |
| 2842 | ELG051 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | If an eligible individual is enrolled in Medicare (DUAL-ELIGIBLE-CODE = "01", "02", "03", "04", "05", "06", "08", "09", or "10"), MEDICARE-BENEFICIARY-IDENTIFIER must be reported. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2843 | ELG051 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | NA | Field should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) until such time as the Medicare Beneficiary Identifier is implemented (no target date has been established). | Not Applicable | 9/23/2015 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG051-0003 |
| 2844 | ELG054 | CHIP-CODE | A code used to distinguish among Medicaid, Medicaid Expansion, and Separate CHIP populations | Required | Value must be equal to a valid value. | 1 Individual was Medicaid-eligible, but was not included in either Medicaid Expansion CHIP or a separate Title XXI CHIP for the month. These include blind and disabled people and low-income families with dependent children. 2 Individual was included in Medicaid Expansion CHIP and subject to enhanced federal matching for the month. States with Medicaid-Expansion programs have built upon existing Medicaid programs to include low-income children whose family incomes are above Medicaid income eligibility thresholds. 3 Individual was not Medicaid Expansion CHIP eligible, but was included in a separate Title XXI CHIP for the month. States using Separate CHIP have used CHIP funds to create separate programs outside of their Medicaid programs. |
8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG054-0001 |
| 2845 | ELG054 | CHIP-CODE | Not Applicable | NA | If the individual transitioned between Medicaid and Separate CHIP, CHIP-ENROLLMENT and MEDICAID-ENROLLMENT dates must not overlap | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG054-0003 |
| 2846 | ELG054 | CHIP-CODE | Not Applicable | NA | If the individual is eligible for Medicaid expansion CHIP (CHIP-CODE = 2) or Separate CHIP (CHIP-CODE = 3) he/she is expected to be reported with ELIGIBILITY-GROUP="61", 62", "63", "64", "65", "66", "67", or "68" | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2847 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | The first day of the time span during which the values in all data elements in the VARIABLE DEMOGRAPHICS - ELIGIBILITY record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG057-0001 |
| 2848 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2849 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2850 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG057-0002 |
| 2851 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the VARIABLE DEMOGRAPHICS– ELIGIBILITY record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG057-0003 |
| 2852 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | The VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE must occur on or before the VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2853 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG057-0004 |
| 2854 | ELG057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG057-0005 |
| 2855 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | The last day of the time span during which the values in all data elements in the VARIABLE DEMOGRAPHICS - ELIGIBILITY record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG058-0001 |
| 2856 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable |
| 2857 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG058-0002 |
| 2858 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG058-0003 |
| 2859 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG058-0004 |
| 2860 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the VARIABLE DEMOGRAPHICS– ELIGIBILITY record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG058-0005 |
| 2861 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | The VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE must occur on or after the VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Not Applicable | 10/10/2013 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG058-0006 |
| 2862 | ELG058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG058-0007 |
| 2863 | ELG059 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG059-0001 |
| 2864 | ELG059 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG059-0002 |
| 2865 | ELG060 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | ELG060-0001 |
| 2866 | ELG061 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG0004 | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG061-0001 |
| 2867 | ELG061 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG061-0003 |
| 2868 | ELG062 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG062-0001 |
| 2869 | ELG062 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG062-0002 |
| 2870 | ELG062 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2871 | ELG062 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG062-0003 |
| 2872 | ELG063 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG063-0001 |
| 2873 | ELG063 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG063-0002 |
| 2874 | ELG063 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG063-0003 |
| 2875 | ELG064 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG064-0001 |
| 2876 | ELG064 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG064-0002 |
| 2877 | ELG064 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG064-0003 |
| 2878 | ELG064 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG064-0004 |
| 2879 | ELG064 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2880 | ELG064 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2881 | ELG064 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG064-0005 |
| 2882 | ELG065 | ADDR-TYPE | The type of address and contact information for the eligible submitted in the record segment. | Required | Value must be equal to a valid value. | 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 |
10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG065-0001 |
| 2883 | ELG065 | ADDR-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG065-0002 |
| 2884 | ELG065 | ADDR-TYPE | Not Applicable | NA | States should report the primary home address and contact information, used for the eligibility (ADDR-TYPE = "01"). More than one address can be reported on separate segments as long as one of the addresses is the primary address. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2885 | ELG066 | ELIGIBLE-ADDR-LN1 | The street address for the type of address indicated. | Required | Line 1 is required and the other two lines can be blank | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG066-0001 |
| 2886 | ELG066 | ELIGIBLE-ADDR-LN1 | Not Applicable | NA | The first line of the address must not be the same as the second or third line of the address (if applicable) | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG066-0002 |
| 2887 | ELG066 | ELIGIBLE-ADDR-LN1 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG066-0003 |
| 2888 | ELG067 | ELIGIBLE-ADDR-LN2 | The street address for the type of address indicated. | Conditional | The field can contain any alphanumeric characters, digits, or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG067-0001 |
| 2889 | ELG067 | ELIGIBLE-ADDR-LN2 | Not Applicable | NA | The second line of the address must not be the same as the first or third line of the address (if applicable) | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG067-0002 |
| 2890 | ELG067 | ELIGIBLE-ADDR-LN2 | Not Applicable | NA | When this data element is not populated or used, States must be blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG067-0003 |
| 2891 | ELG068 | ELIGIBLE-ADDR-LN3 | The street address for the type of address indicated. | Conditional | The field can contain any alphanumeric characters, digits, or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG068-0001 |
| 2892 | ELG068 | ELIGIBLE-ADDR-LN3 | Not Applicable | NA | Line 1 is required and the other two lines can be blank | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG068-0002 |
| 2893 | ELG068 | ELIGIBLE-ADDR-LN3 | Not Applicable | NA | The third line of the address must not be the same as the first or second line of the address (if applicable) | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG068-0003 |
| 2894 | ELG068 | ELIGIBLE-ADDR-LN3 | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG068-0004 |
| 2895 | ELG069 | ELIGIBLE-CITY | The city for the type of address indicated in ADDR-TYPE. | Required | The city for the eligible individual's address must be reported. | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG069-0001 |
| 2896 | ELG069 | ELIGIBLE-CITY | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG069-0002 |
| 2897 | ELG070 | ELIGIBLE-STATE | The ANSI state numeric for the U.S. state, Territory, or the District of Columbia code for where the individual eligible to receive healthcare services resides. (The state for the type of address indicated in ADDR-TYPE.) | Required | The state for the eligible individual's address must be reported. | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG070-0001 |
| 2898 | ELG070 | ELIGIBLE-STATE | Not Applicable | NA | The field must be populated on every record | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG070-0002 |
| 2899 | ELG070 | ELIGIBLE-STATE | Not Applicable | Required | Value must be equal to a valid value. | http://www.census.gov/geo/reference/ansi_statetables.html | 10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG070-0003 |
| 2900 | ELG071 | ELIGIBLE-ZIP-CODE | The zip code for the type of address indicated in ADDR-TYPE. | Required | First 5 bytes (i.e., the 5-digit zip code) is required | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG071-0001 |
| 2901 | ELG071 | ELIGIBLE-ZIP-CODE | Not Applicable | NA | Last 4 bytes are optional. If the last 4 digits are not populated or used, then the 4-digit extended zip code should be recorded as “0000”. | Not Applicable | 9/23/2015 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG071-0002 |
| 2902 | ELG071 | ELIGIBLE-ZIP-CODE | Not Applicable | NA | The value must consist of digits 0 through 9 only | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG071-0003 |
| 2903 | ELG072 | ELIGIBLE-COUNTY-CODE | ANSI county numeric code indicating the county for the type of address indicated in ADDR-TYPE. | Required | Dependent value must be equal to a valid value. | http://www.census.gov/geo/reference/codes/countylookup.html | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG072-0001 |
| 2904 | ELG072 | ELIGIBLE-COUNTY-CODE | Not Applicable | NA | The county for the eligible individual's address must be reported. | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG072-0002 |
| 2905 | ELG072 | ELIGIBLE-COUNTY-CODE | Not Applicable | NA | Value must be numeric. | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG072-0003 |
| 2906 | ELG073 | ELIGIBLE-PHONE-NUM | The telephone number of the type of address indicated. | Required | The phone number for the eligible individual must be reported. | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG073-0001 |
| 2907 | ELG073 | ELIGIBLE-PHONE-NUM | Not Applicable | NA | Enter digits only (i.e., no parentheses, dashes, periods, commas, spaces, etc.) | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG073-0002 |
| 2908 | ELG074 | TYPE-OF-LIVING-ARRANGEMENT | A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid values listing. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG074-0001 |
| 2909 | ELG074 | TYPE-OF-LIVING-ARRANGEMENT | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG074-0002 |
| 2910 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | The first day of the time span during which the values in all data elements on an ELIGIBLE-CONTACT-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG075-0001 |
| 2911 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2912 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG075-0002 |
| 2913 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG075-0003 |
| 2914 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the ELIGIBLE-CONTACT-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2915 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | Not Applicable | NA | The ELIGIBLE-ADDR-EFF-DATE must occur on or before the ELIGIBLE-ADDR-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2916 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG075-0005 |
| 2917 | ELG075 | ELIGIBLE-ADDR-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG075-0006 |
| 2918 | ELG076 | ELIGIBLE-ADDR-END-DATE | The last day of the time span during which the values in all data elements on an ELIGIBLE-CONTACT-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG076-0001 |
| 2919 | ELG076 | ELIGIBLE-ADDR-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2920 | ELG076 | ELIGIBLE-ADDR-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG076-0002 |
| 2921 | ELG076 | ELIGIBLE-ADDR-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG076-0003 |
| 2922 | ELG076 | ELIGIBLE-ADDR-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG076-0004 |
| 2923 | ELG076 | ELIGIBLE-ADDR-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the ELIGIBLE-CONTACT-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG076-0005 |
| 2924 | ELG076 | ELIGIBLE-ADDR-END-DATE | Not Applicable | NA | The ELIGIBLE-ADDR-END-DATE must occur on or after the PRIMARY-ELIGIBLE-ADDR-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable |
| 2925 | ELG076 | ELIGIBLE-ADDR-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG076-0006 |
| 2926 | ELG077 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG077-0001 |
| 2927 | ELG077 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG077-0002 |
| 2928 | ELG078 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | ELG078-0001 |
| 2929 | ELG079 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00005 | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG079-0003 |
| 2930 | ELG079 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG079-0001 |
| 2931 | ELG080 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG080-0002 |
| 2932 | ELG080 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG080-0001 |
| 2933 | ELG080 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 2934 | ELG080 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG080-0003 |
| 2935 | ELG081 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG081-0001 |
| 2936 | ELG081 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG081-0002 |
| 2937 | ELG081 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG081-0003 |
| 2938 | ELG082 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG082-0001 |
| 2939 | ELG082 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG082-0002 |
| 2940 | ELG082 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG082-0003 |
| 2941 | ELG082 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG082-0004 |
| 2942 | ELG082 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 2943 | ELG082 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 2944 | ELG082 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG082-0005 |
| 2945 | ELG083 | MSIS-CASE-NUM | The state-assigned number which uniquely identifies the Medicaid case to which the enrollee belongs. The definition of a case varies. There are single-person cases (mostly aged and blind/disabled) and multi-person cases (mostly TANF) in which all members of the case have the same case number, but a unique MSIS identification number. A warning for longitudinal research efforts: a person’s case number may change over time. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG083-0001 |
| 2946 | ELG083 | MSIS-CASE-NUM | Not Applicable | NA | This field must contain the Medicaid case identification number assigned by the state. The format of the Medicaid case identification number must be supplied to CMS. | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG083-0002 |
| 2947 | ELG083 | MSIS-CASE-NUM | Not Applicable | NA | If multiple MSIS-CASE-NUMs exist at the state-level, and T-MSIS only allows one Case Number in current T-MSIS DD, please enter the Case Number with the longest eligibility days in that particular month. | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG083-0003 |
| 2948 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | A code indicating the individual’s Medicaid eligibility for the coverage period (not including separate CHIP). Note: This data element will be phased out in lieu of ELIGIBILITY-GROUP. | Conditional | Value must be equal to a valid value. | 00 Eligible for Separate CHIP only 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 |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0001 |
| 2949 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | If an individual's MAINTENANCE-ASSISTANCE-STATUS indicates he/she is eligible for Separate CHIP only ("0"), then MEDICAID-BASIS-OF-ELIGIBILITY must also indicate he/she is eligible for Separate CHIP only (equal to "00"). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0003 |
| 2950 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | If an eligible individual has a MEDICAID-BASIS-OF-ELIGIBILITY of Foster Care Child ("08"), then MAINTENANCE-ASSISTANCE-STATUS must be designated as Other ("4"). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0004 |
| 2951 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | If an eligible individual has a MEDICAID-BASIS-OF-ELIGIBILITY of Child of an Unemployed Adult ("06") or Unemployed Adult ("07"), then MAINTENANCE-ASSISTANCE STATUS must be designated as Receiving Cash or eligible under section 1931 of the Act ("1"). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0005 |
| 2952 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | If an eligible individual has a MEDICAID-BASIS-OF-ELIGIBILITY of Individual covered under the Breast and Cervical Cancer Prevention and Treatment Act of 2000 ("11"), then MAINTENANCE-ASSISTANCE-STATUS must be designated as Poverty Related ("3"). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0006 |
| 2953 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | If an eligible individual has a MEDICAID-BASIS-OF-ELIGIBILITY of Aged individual ("01"), then his/her date of birth must imply the Recipient was over 64. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0007 |
| 2954 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | If an eligible individual has a MEDICAID-BASIS-OF-ELIGIBILITY of Child ("04") (not Child of Unemployed Adult, not Foster Care) or Child of an Unemployed Adult ("06"), then his/her date of birth must imply the Recipient was under 21. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0008 |
| 2955 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | Required on ELIGIBILITY-DETERMINANT segments with effective dates before January 1, 2014. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 2956 | ELG084 | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | NA | The MEDICAID-BASIS-OF-ELIGIBILITY (BOE) and MAINTENANCE-ASSISTANCE-STATUS (MAS) fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) for enrollment periods beginning on or after January 1, 2014. If the segment date span contains January 1, 2014, MAS and BOE should continue to be reported until the individual undergoes Medicaid eligibility redetermination. If not already, after redetermination, the individual must be assigned a T-MSIS ELIGIBILITY-GROUP. After redetermination, MAS and BOE are no longer required. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG084-0009 |
| 2957 | ELG085 | DUAL-ELIGIBLE-CODE | Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG085-0001 |
| 2958 | ELG085 | DUAL-ELIGIBLE-CODE | Not Applicable | NA | IGNORE -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. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG085-0002 |
| 2959 | ELG085 | DUAL-ELIGIBLE-CODE | Not Applicable | NA | If the eligible individual is a partial dual eligible, then he/she must have a MAINTENANCE-ASSISTANCE-STATUS of "3" (Poverty-related). Note: MAINTENANCE-ASSISTANCE-STATUS is only required on ELIGIBILITY-DETERMINANT segments with either (1) both effective and end dates before January 1, 2014 or (2) effective date before January 1, 2014 and end date after January 1, 2014, until the individual undergoes Medicaid eligibility redetermination. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG085-0003 |
| 2960 | ELG085 | DUAL-ELIGIBLE-CODE | Not Applicable | NA | If the eligible individual is a partial dual eligible, then he/she must have a RESTRICTED-BENEFITS-CODE = "3". | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 2961 | ELG085 | DUAL-ELIGIBLE-CODE | Not Applicable | NA | If the eligible individual is not a dual eligible, he/she must not have a Medicare Beneficiary Identifier | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG085-0004 |
| 2962 | ELG085 | DUAL-ELIGIBLE-CODE | Not Applicable | NA | If the Medicaid eligible individual is a dual eligible then MAINTENANCE-ASSISTANCE-STATUS cannot equal "0" indicating that he/she is not eligible for Medicaid. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG085-0006 |
| 2963 | ELG085 | DUAL-ELIGIBLE-CODE | Not Applicable | NA | DUAL-ELIGIBLE-CODE ‘08’ is intended to capture full duals who are not eligible for Medicaid as a QMB, SLMB, QDWI, or QI-1. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid eligibility poverty group that exceeds the limits established for other dual classifications. Regarding full duals who can be distinguished separately, states, when possible, should not lump these duals in this code and should instead assign them to one of the other full dual codes. The 08 code should be considered a catch-all for all remaining full duals. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG085-0007 |
| 2964 | ELG085 | DUAL-ELIGIBLE-CODE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Dual-Eligible Code" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG085-0008 |
| 2965 | ELG086 | PRIMARY-ELIGIBILITY-GROUP-IND | A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. | Required | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG086-0001 |
| 2966 | ELG086 | PRIMARY-ELIGIBILITY-GROUP-IND | Not Applicable | NA | A person enrolled in Medicaid/CHIP should always have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.) It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES). |
Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG086-0002 |
| 2967 | ELG086 | PRIMARY-ELIGIBILITY-GROUP-IND | Not Applicable | NA | Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG086-0003 |
| 2968 | ELG086 | PRIMARY-ELIGIBILITY-GROUP-IND | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: PRIMARY-ELIGIBILITY-GROUP-IND" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG086-0004 |
| 2969 | ELG087 | ELIGIBILITY-GROUP | The eligibility group applicable to the individual based on the eligibility determination process. The valid value list of eligibility groups aligns with those being used in the Medicaid and CHIP Program Data System (MACPro). | Conditional | Value must be equal to a valid value. | See Appendix F – Eligibility Group Table | 11/3/2015 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG087-0001 |
| 2970 | ELG087 | ELIGIBILITY-GROUP | Not Applicable | NA | Required on all ELIGIBILITY-DETERMINANTS segments with an effective date of January 1, 2014 or later. If the segment date span contains January 1, 2014, if not already assigned an ELIGIBILITY-GROUP, the individual must be assigned an ELIGIBILITY-GROUP once undergone Medicaid eligibility redetermination. ELIGIBILITY-GROUP is not required for on segments ending before January 1, 2014. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 2971 | ELG087 | ELIGIBILITY-GROUP | Not Applicable | NA | Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE=7 and STATE-PLAN-OPTION-TYPE="06" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG087-0002 |
| 2972 | ELG087 | ELIGIBILITY-GROUP | Not Applicable | NA | If the individual is eligible for Medicaid expansion CHIP (CHIP-CODE = 2) or Separate CHIP (CHIP-CODE = 3) he/she is expected to be reported with ELIGIBILITY-GROUP="61", 62", "63", "64", "65", "66", "67", or "68" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 2973 | ELG087 | ELIGIBILITY-GROUP | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Alternative Benefit Plans" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG087-0003 |
| 2974 | ELG087 | ELIGIBILITY-GROUP | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Eligibility Group" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG087-0004 |
| 2975 | ELG088 | LEVEL-OF-CARE-STATUS | The level of care required to meet an individual's needs and to determine LTSS program eligibility. | Conditional | Value must be equal to a valid value. | 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) |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG088-0001 |
| 2976 | ELG089 | SSDI-IND | A flag indicating if the individual is enrolled in Social Security Disability Insurance (SSDI) administered via the Social Security Administration (SSA). | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG089-0001 |
| 2977 | ELG090 | SSI-IND | A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA). | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG090-0001 |
| 2978 | ELG090 | SSI-IND | Not Applicable | NA | If an eligible individual is receiving SSI, then his/her SSI Status cannot be considered not applicable. | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG090-0002 |
| 2979 | ELG091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | Indicates the individual's SSI State Supplemental Status. | Conditional | Value must be equal to a valid value. | 000 Not Applicable 001 Mandatory 002 Optional |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG091-0001 |
| 2980 | ELG091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | Not Applicable | NA | An eligible individual should not receive SSI State Supplements if they are not receiving SSI. | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG091-0002 |
| 2981 | ELG092 | SSI-STATUS | Indicates the individual's SSI Status. | Conditional | Value must be equal to a valid value. | 000 Not Applicable 001 SSI 002 SSI Eligible Spouse 003 SSI Pending a Final Determination of Disposal of Resources Exceeding SSI Dollar Limits |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG092-0001 |
| 2982 | ELG092 | SSI-STATUS | Not Applicable | NA | An eligible individual cannot have an SSI Status if they are not receiving SSI or if his/her SSI status is pending decision. | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG092-0002 |
| 2983 | ELG093 | STATE-SPEC-ELIG-GROUP | The composite of eligibility mapping factors used to create the corresponding Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) values (before January 1, 2014) and ELIGIBILITY-GROUP values (on or after January 1, 2014). This field should not include information that already appears elsewhere on the Eligible-File record even if it is part of the MAS and BOE or ELIGIBILITY-GROUP algorithm (e.g., age information computed from DATE-OF-BIRTH or COUNTY-CODE). |
Required | Concatenate alpha numeric representations of the eligibility mapping factors used to create MAS and BOE and/or ELIGIBILITY-GROUP. State needs to provide composite code reflecting the contents of this field (e.g., bytes 1-2 = aid category; bytes 3 = money code; bytes 4-5 = person code). If six bytes is insufficient to accommodate all of the eligibility factors, the state should select the most critical factors and include them in this field. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG093-0001 |
| 2984 | ELG093 | STATE-SPEC-ELIG-GROUP | Not Applicable | NA | If the value for STATE-SPEC-ELIG-GROUP is between 000000 and 999999, then DATE-OF-DEATH cannot be before the start of the reporting period. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG093-0002 |
| 2985 | ELG093 | STATE-SPEC-ELIG-GROUP | Not Applicable | NA | Value must be one of the valid codes submitted by the State. (States must submit lists of valid State specific eligibility factor codes to CMS in advance of transmitting T-MSIS files, and must update those lists whenever changes occur.) | Not Applicable | 2/25/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG093-0003 |
| 2986 | ELG093 | STATE-SPEC-ELIG-GROUP | Not Applicable | NA | For this field, always report whatever is present in the State system, even if it is clearly invalid.leave blank or space-fill only when the State system contains no information | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG093-0004 |
| 2987 | ELG093 | STATE-SPEC-ELIG-GROUP | Not Applicable | NA | If value > 000000 and < 999999, DATE-OF-DEATH cannot be less than the reporting period. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG093-0005 |
| 2988 | ELG093 | STATE-SPEC-ELIG-GROUP | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Alternative Benefit Plans" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG093-0006 |
| 2989 | ELG094 | CONCEPTION-TO-BIRTH-IND | A flag to identify children eligible through the conception to birth option, which is available only through a Separate CHIP Program. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG094-0001 |
| 2990 | ELG094 | CONCEPTION-TO-BIRTH-IND | Not Applicable | NA | If the individual is a child eligible through the conception to birth option, then the individual must have his/her eligibility indicate that he/she is eligible only through a Separate CHIP program. ELIGIBILITY-GROUP must be "64". | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG094-0002 |
| 2991 | ELG094 | CONCEPTION-TO-BIRTH-IND | Not Applicable | NA | If an individual is eligible through the conception to birth option, then any associated claims for the individual must indicate the program type for the claim as State Plan CHIP (Program Type "14"). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG094-0003 |
| 2992 | ELG094 | CONCEPTION-TO-BIRTH-IND | Not Applicable | NA | The CHIP-CODE must equal “3” (Individual was not Medicaid-Expansion CHIP eligible, but was included in a separate title XXI CHIP program) or “4” (Individual was both Medicaid eligible and Separate CHIP eligible.) | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG094-0004 |
| 2993 | ELG095 | ELIGIBILITY-CHANGE-REASON | The reason for a change in an individual's eligibility status. Report this reason when there is a change in the individual's eligibility status. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG095-0001 |
| 2994 | ELG096 | MAINTENANCE-ASSISTANCE-STATUS | A code indicating the individual’s maintenance assistance status. See Appendix C for a description of MSIS coding categories. Note: This data element will be phased out in lieu of ELIGIBILITY-GROUP. | Conditional | Value must be equal to a valid value. | 0 Eligible for Separate CHIP only 1 Receiving Cash or eligible under section 1931 of the Act 2 Medically Needy 3 Poverty Related 4 Other 5 1115 - Demonstration expansion eligible |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG096-0001 |
| 2995 | ELG096 | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | NA | If the individual has a MAINTENANCE-ASSISTANCE-STATUS indicating he/she is eligible for Medicaid, then his/her DATE-OF-DEATH cannot have occurred before the start of the time period for the file submission. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG096-0002 |
| 2996 | ELG096 | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | NA | If an eligible individual's MEDICAID-BASIS-OF-ELIGIBILITY indicates he/she is eligible for Separate CHIP only (equal to "00"), then MAINTENANCE-ASSISTANCE-STATUS must also indicate he/she is eligible for Separate CHIP only ("0"). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG096-0003 |
| 2997 | ELG096 | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | NA | If an individual's MEDICAID-BASIS-OF-ELIGIBILITY indicates he/she is eligible for Medicaid, then MAINTENANCE-ASSISTANCE-STATUS must also indicate he/she is eligible for Medicaid. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG096-0004 |
| 2998 | ELG096 | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | NA | If an individual is not eligible, then he/she must have a populated Medicaid Enrollment End Date. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG096-0005 |
| 2999 | ELG096 | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | NA | Required on ELIGIBILITY-DETERMINANTS segments with effective dates before January 1, 2014. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 3000 | ELG096 | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | NA | The MEDICAID-BASIS-OF-ELIGIBILITY (BOE) and MAINTENANCE-ASSISTANCE-STATUS (MAS) fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files) for enrollment periods beginning on or after January 1, 2014. If the segment date span contains January 1, 2014, MAS and BOE should continue to be reported until the individual undergoes Medicaid eligibility redetermination. If not already, after redetermination, the individual must be assigned a T-MSIS ELIGIBILITY-GROUP. After redetermination, MAS and BOE are no longer required. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG096-0006 |
| 3001 | ELG097 | RESTRICTED-BENEFITS-CODE | A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097-0001 |
| 3002 | ELG097 | RESTRICTED-BENEFITS-CODE | Not Applicable | NA | If the individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status (RESTRICTED-BENEFITS-CODE = "3"), then his/her dual eligible status must indicate he/she is a partial dual eligible (DUAL-ELIGIBLE-CODE = "1" (QMB only), "3" (SLMB only), "5" (QDWI), or "6" (QI). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097-0002 |
| 3003 | ELG097 | RESTRICTED-BENEFITS-CODE | Not Applicable | NA | If the individual is eligible for Medicaid or CHIP but only entitled to restricted benefits for pregnancy-related services, then SEX must equal “F” | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097-0003 |
| 3004 | ELG097 | RESTRICTED-BENEFITS-CODE | Not Applicable | NA | If an individual receives restricted benefits based on his/her alien status (RESTRICTED-BENEFITS-CODE = "2"), then he/she must not be a U.S. citizen (CITIZENSHIP-IND = "0") | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097-0005 |
| 3005 | ELG097 | RESTRICTED-BENEFITS-CODE | Not Applicable | NA | If an individual's restricted benefits status indicates that they are entitled to any level of Medicaid or CHIP benefits, then his/her Maintenance Assistance Status and Basis of Eligibility and/or ELIGIBILITY-GROUP cannot indicate he/she is not eligible. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097-0006 |
| 3006 | ELG097 | RESTRICTED-BENEFITS-CODE | Not Applicable | NA | If an individual's restricted benefits status indicated they are entitled to benefits under Money Follows the Person (RESTRICTED-BENEFITS-CODE = "D"), then he/she must have a corresponding MFP enrollment segment with effect and end dates that are within or the same as the effective and end dates of Eligibility Determinant record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097-0007 |
| 3007 | ELG097 | RESTRICTED-BENEFITS-CODE | Not Applicable | NA | Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE="7" and STATE-PLAN-OPTION-TYPE="06" | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG097-0008 |
| 3008 | ELG098 | TANF-CASH-CODE | A flag that indicates whether the individual received Federal Temporary Assistance for Needy Families (TANF) benefits. | Conditional | Value must be equal to a valid value. | 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) |
8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG098-0001 |
| 3009 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | The start date of an individual's reported Eligibility Status. This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG099-0001 |
| 3010 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | NA | If it is unknown when eligibility status became effective OR if a complete, valid date is not available, thenleave blank, or space-fill. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG099-0003 |
| 3011 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG099-0004 |
| 3012 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG099-0005 |
| 3013 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | NA | The ELIGIBILITY-DETERMINANT-EFF-DATE must occur on or before the ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG099-0006 |
| 3014 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the ELIGIBILITY-DETERMINANTS record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 3015 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG099-0007 |
| 3016 | ELG099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG099-0008 |
| 3017 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | The date that an individual's reported Eligibility Status ended. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG100-0001 |
| 3018 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG100-0003 |
| 3019 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG100-0004 |
| 3020 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG100-0005 |
| 3021 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 3022 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the ELIGIBLE-DETERMINANTS record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG100-0006 |
| 3023 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | NA | The ELIGIBILITY-DETERMINANT-END-DATE must occur on or after the ELIGIBILITY-DETERMINANT-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable |
| 3024 | ELG100 | ELIGIBILITY-DETERMINANT-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG100-0007 |
| 3025 | ELG101 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG101-0001 |
| 3026 | ELG101 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG101-0002 |
| 3027 | ELG102 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | ELG102-0001 |
| 3028 | ELG103 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00006 | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG103-0003 |
| 3029 | ELG103 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG103-0001 |
| 3030 | ELG104 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG104-0002 |
| 3031 | ELG104 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG104-0001 |
| 3032 | ELG104 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3033 | ELG104 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG104-0003 |
| 3034 | ELG105 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG105-0001 |
| 3035 | ELG105 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG105-0002 |
| 3036 | ELG105 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG105-0003 |
| 3037 | ELG106 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG106-0001 |
| 3038 | ELG106 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG106-0002 |
| 3039 | ELG106 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG106-0003 |
| 3040 | ELG106 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG106-0004 |
| 3041 | ELG106 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3042 | ELG106 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3043 | ELG106 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG106-0005 |
| 3044 | ELG107 | HEALTH-HOME-SPA-NAME | A free-form text field for the name of the health home program approved by CMS. This name needs to be consistent across files to be used for linking. | Conditional | Left justify and right-fill unused bytes with spaces | Not Applicable | 11/3/2015 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG107-0001 |
| 3045 | ELG107 | HEALTH-HOME-SPA-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG107-0002 |
| 3046 | ELG107 | HEALTH-HOME-SPA-NAME | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG107-0003 |
| 3047 | ELG108 | HEALTH-HOME-ENTITY-NAME | A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities’ names are being used instead. | Conditional | Required on every HEALTH-HOME-SPA-PARTICIPATION-INFORMATION record | Not Applicable | 11/3/2015 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG108-0001 |
| 3048 | ELG108 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG108-0002 |
| 3049 | ELG108 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | Right-fill unused bytes if name is less than 100 bytes long | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG108-0003 |
| 3050 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | The date on which the individual’s participation in the Health Home Program started. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG109-0001 |
| 3051 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG109-0003 |
| 3052 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG109-0004 |
| 3053 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG109-0005 |
| 3054 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the HEALTH-HOME-SPA-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3055 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | NA | The HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE must occur on or before the HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG109-0006 |
| 3056 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG109-0008 |
| 3057 | ELG109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG109-0009 |
| 3058 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | The date on which the individual’s participation in the Health Home Program ended. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG110-0001 |
| 3059 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG110-0003 |
| 3060 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG110-0004 |
| 3061 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG110-0005 |
| 3062 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3063 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG110-0006 |
| 3064 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | NA | The HEALTH-HOME-SPA-PARTICIPATION-END-DATE must occur on or after the HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG110-0007 |
| 3065 | ELG110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG110-0008 |
| 3066 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | The date on which the health home entity was approved by CMS to participate in the Health Home Program. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG111-0001 |
| 3067 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG111-0002 |
| 3068 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG111-0004 |
| 3069 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG111-0005 |
| 3070 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | The HEALTH-HOME-ENTITY-EFF-DATE must occur on or before the HEALTH-HOME-ENTITY-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3071 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the HEALTH-HOME-SPA-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3072 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3073 | ELG111 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable |
| 3074 | ELG112 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG112-0001 |
| 3075 | ELG112 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG112-0002 |
| 3076 | ELG113 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | ELG113-0001 |
| 3077 | ELG114 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00007 | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG114-0003 |
| 3078 | ELG114 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG114-0001 |
| 3079 | ELG115 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG115-0002 |
| 3080 | ELG115 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG115-0001 |
| 3081 | ELG115 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable |
| 3082 | ELG115 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG115-0003 |
| 3083 | ELG116 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG116-0001 |
| 3084 | ELG116 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG116-0002 |
| 3085 | ELG116 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG116-0003 |
| 3086 | ELG117 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG117-0001 |
| 3087 | ELG117 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG117-0002 |
| 3088 | ELG117 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG117-0003 |
| 3089 | ELG117 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG117-0004 |
| 3090 | ELG117 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable |
| 3091 | ELG117 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable |
| 3092 | ELG117 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG117-0005 |
| 3093 | ELG118 | HEALTH-HOME-SPA-NAME | A free-form text field for the name of the health home program approved by CMS. This name needs to be consistent across files to be used for linking. | Conditional | Left justify and right-fill unused bytes with spaces | Not Applicable | 11/3/2015 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG118-0001 |
| 3094 | ELG118 | HEALTH-HOME-SPA-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG118-0002 |
| 3095 | ELG119 | HEALTH-HOME-ENTITY-NAME | A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities’ names are being used instead. | Conditional | Required on every HEALTH-HOME-SPA-PARTICIPATION-INFORMATION record | Not Applicable | 11/3/2015 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG119-0001 |
| 3096 | ELG119 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | If the value for STATE-SPEC-ELIG-GROUP is a valid, non-missing value, then DATE-OF-DEATH cannot be before ELIGIBILITY-DETERMINANTS-EFF-DATE. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG119-0002 |
| 3097 | ELG119 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG119-0003 |
| 3098 | ELG119 | HEALTH-HOME-ENTITY-NAME | Not Applicable | NA | When this data element is not populated or used, it should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG119-0004 |
| 3099 | ELG120 | HEALTH-HOME-PROV-NUM | A unique identification number assigned by the state to the individual’s primary care manager for the Health Home in which the individual is enrolled. | Conditional | Required on every HEALTH-HOME-SPA-PROVIDERS record | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG120-0002 |
| 3100 | ELG120 | HEALTH-HOME-PROV-NUM | Not Applicable | NA | Value must exist in the state’s submitted provider information | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG120-0003 |
| 3101 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | The date on which the eligible individual’s affiliation with the health home entity for the provision of health home services became effective. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG121-0001 |
| 3102 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG121-0003 |
| 3103 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | NA | If an individual is eligible through the conception to birth option, then the CHIP-CODE must equal “3” (Individual was not Medicaid-Expansion CHIP eligible, but was included in a separate title XXI CHIP program). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG121-0004 |
| 3104 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG121-0005 |
| 3105 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | NA | The HEALTH-HOME-SPA-PROVIDER-EFF-DATE must occur on or before the HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG121-0006 |
| 3106 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the HEALTH-HOME-SPA-PROVIDERS record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable |
| 3107 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG121-0008 |
| 3108 | ELG121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG121-0009 |
| 3109 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | The date on which the eligible individual’s affiliation with the health home entity for the provision of health home services ended. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG122-0001 |
| 3110 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG122-0003 |
| 3111 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG122-0004 |
| 3112 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG122-0005 |
| 3113 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable |
| 3114 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the HEALTH-HOME-SPA-PROVIDERS record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG122-0006 |
| 3115 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | NA | The HEALTH-HOME-SPA-PROVIDER-END-DATE must occur on or after the HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable |
| 3116 | ELG122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG122-0007 |
| 3117 | ELG123 | HEALTH-HOME-ENTITY-EFF-DATE | The date on which the health home entity was approved by CMS to participate in the Health Home Program. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG123-0001 |
| 3118 | ELG123 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG123-0002 |
| 3119 | ELG123 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG123-0004 |
| 3120 | ELG123 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG123-0005 |
| 3121 | ELG123 | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | NA | Value must be equal to or less than START-OF-TIME-PERIOD. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG123-0006 |
| 3122 | ELG124 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG124-0001 |
| 3123 | ELG124 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG124-0002 |
| 3124 | ELG125 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | ELG125-0001 |
| 3125 | ELG126 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00008 | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG126-0003 |
| 3126 | ELG126 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG126-0001 |
| 3127 | ELG127 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG127-0002 |
| 3128 | ELG127 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG127-0001 |
| 3129 | ELG127 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable |
| 3130 | ELG127 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG127-0003 |
| 3131 | ELG128 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG128-0001 |
| 3132 | ELG128 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG128-0002 |
| 3133 | ELG128 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG128-0003 |
| 3134 | ELG129 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG129-0001 |
| 3135 | ELG129 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG129-0002 |
| 3136 | ELG129 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG129-0003 |
| 3137 | ELG129 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG129-0004 |
| 3138 | ELG129 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable |
| 3139 | ELG129 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable |
| 3140 | ELG129 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG129-0005 |
| 3141 | ELG130 | HEALTH-HOME-CHRONIC-CONDITION | The chronic condition used to determine the individual's eligibility for the health home provision. | Conditional | Value must be equal to a valid value. | A Mental health B Substance abuse C Asthma D Diabetes E Heart disease F Overweight (BMI of >25) G HIV/AIDS H Other |
11/3/2015 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG130-0001 |
| 3142 | ELG130 | HEALTH-HOME-CHRONIC-CONDITION | Not Applicable | NA | If value H (Other) is selected, identify the chronic condition in HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION. | Not Applicable | 4/30/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG130-0002 |
| 3143 | ELG131 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | A free-text field to capture the description of the other chronic condition (or conditions) when value “H” (Other) appears in the HEALTH-HOME-CHRONIC-CONDITION. | Conditional | Conditional (required when value “H” (Other) appears in HEALTH-HOME-CHRONIC-CONDITION | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG131-0001 |
| 3144 | ELG131 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG131-0002 |
| 3145 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | The first day of the time span during which the values in all data elements on a HEALTH-HOME-CHRONIC-CONDITIONS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0001 |
| 3146 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0003 |
| 3147 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0004 |
| 3148 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0005 |
| 3149 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | NA | The HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE must occur on or before the HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0006 |
| 3150 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the HEALTH-HOME-CHRONIC-CONDITIONS record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0007 |
| 3151 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0008 |
| 3152 | ELG132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG132-0009 |
| 3153 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | The last day of the time span during which the values in all data elements on a HEALTH-HOME-CHRONIC-CONDITIONS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG133-0001 |
| 3154 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG133-0003 |
| 3155 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG133-0004 |
| 3156 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG133-0005 |
| 3157 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 10/10/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG133-0006 |
| 3158 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the HEALTH-HOME-CHRONIC-CONDITIONS record segment changes, a new record segment must be created | Not Applicable | 10/10/2013 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG133-0007 |
| 3159 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | NA | The HEALTH-HOME-CHRONIC-CONDITION-END-DATE must occur on or after the HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable |
| 3160 | ELG133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG133-0008 |
| 3161 | ELG134 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG134-0001 |
| 3162 | ELG134 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG134-0002 |
| 3163 | ELG135 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | ELG135-0001 |
| 3164 | ELG136 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00009 | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG136-0003 |
| 3165 | ELG136 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG136-0001 |
| 3166 | ELG137 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG137-0002 |
| 3167 | ELG137 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG137-0001 |
| 3168 | ELG137 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable |
| 3169 | ELG137 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG137-0003 |
| 3170 | ELG138 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG138-0001 |
| 3171 | ELG138 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG138-0002 |
| 3172 | ELG138 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG138-0003 |
| 3173 | ELG139 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG139-0001 |
| 3174 | ELG139 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG139-0002 |
| 3175 | ELG139 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG139-0003 |
| 3176 | ELG139 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG139-0004 |
| 3177 | ELG139 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable |
| 3178 | ELG139 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable |
| 3179 | ELG139 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG139-0005 |
| 3180 | ELG140 | LOCKIN-PROV-NUM | A unique identification number assigned by the state to a provider furnishing locked-in healthcare services to an individual. | Conditional | Valid formats must be supplied by the state in advance of submitting file data | Not Applicable | 11/3/2015 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG140-0001 |
| 3181 | ELG141 | LOCKED-IN-SRVCS | The type(s) of service that are locked-in. | Conditional | (1) "Enter the TYPE-OF-SERVICE code that describes the services being locked-in." (2) "Enter one TYPE-OF-SERVICE code per LOCK-IN-INFORMATION-ELG00009 record segment." (3) "If more than one TYPE-OF-SERVICE is being locked-in, create a separate LOCK-IN-INFORMATION-ELG00009 record segment for each. |
See Appendix A for listing of valid values. | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG141-0001 |
| 3182 | ELG142 | LOCKIN-EFF-DATE | The date on which the lock in period begins for an individual with a healthcare service/provider. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG142-0001 |
| 3183 | ELG142 | LOCKIN-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG142-0003 |
| 3184 | ELG142 | LOCKIN-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG142-0004 |
| 3185 | ELG142 | LOCKIN-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG142-0005 |
| 3186 | ELG142 | LOCKIN-EFF-DATE | Not Applicable | NA | The LOCKIN-EFF-DATE must occur on or before the LOCKIN-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG142-0006 |
| 3187 | ELG142 | LOCKIN-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the LOCK-IN-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable |
| 3188 | ELG142 | LOCKIN-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG142-0007 |
| 3189 | ELG142 | LOCKIN-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG142-0008 |
| 3190 | ELG143 | LOCKIN-END-DATE | The date on which the lock in period ends for an individual with a healthcare service/provider. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG143-0001 |
| 3191 | ELG143 | LOCKIN-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG143-0003 |
| 3192 | ELG143 | LOCKIN-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG143-0004 |
| 3193 | ELG143 | LOCKIN-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG143-0005 |
| 3194 | ELG143 | LOCKIN-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable |
| 3195 | ELG143 | LOCKIN-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the LOCK-IN-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG143-0006 |
| 3196 | ELG143 | LOCKIN-END-DATE | Not Applicable | NA | The LOCKIN-END-DATE must occur on or after the LOCKIN-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable |
| 3197 | ELG143 | LOCKIN-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG143-0007 |
| 3198 | ELG144 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG144-0001 |
| 3199 | ELG144 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG144-0002 |
| 3200 | ELG145 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | ELG145-0001 |
| 3201 | ELG146 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00010 | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG146-0003 |
| 3202 | ELG146 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG146-0001 |
| 3203 | ELG147 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG147-0002 |
| 3204 | ELG147 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG147-0001 |
| 3205 | ELG147 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3206 | ELG147 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG147-0003 |
| 3207 | ELG148 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG148-0001 |
| 3208 | ELG148 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG148-0002 |
| 3209 | ELG148 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG148-0003 |
| 3210 | ELG149 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG149-0001 |
| 3211 | ELG149 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG149-0002 |
| 3212 | ELG149 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG149-0003 |
| 3213 | ELG149 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG149-0004 |
| 3214 | ELG149 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3215 | ELG149 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3216 | ELG149 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG149-0005 |
| 3217 | ELG150 | MFP-LIVES-WITH-FAMILY | A code indicating if the individual lives with his/her family or is not a participant in the MFP program. | Conditional | Value must be equal to a valid value. | 0 NO 1 YES 2 No MFP Participation |
8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG150-0001 |
| 3218 | ELG151 | MFP-QUALIFIED-INSTITUTION | A code describing type of qualified institution at the time of transition to the community for an eligible MFP Demonstration participant. | Conditional | Value must be equal to a valid value. | 00 Default- No MFP 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 |
8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG151-0001 |
| 3219 | ELG152 | MFP-QUALIFIED-RESIDENCE | A code indicating the type of qualified residence. | Conditional | Value must be equal to a valid value. | 00 Default - No MFP 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 |
8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG152-0001 |
| 3220 | ELG153 | MFP-REASON-PARTICIPATION-ENDED | A code describing reason why individual’s participation in the Money Follows the Person Demonstration ended. | Conditional | Value must be equal to a valid value. | 00 Default – No MFP Participation 01 Completed 365 days of participation 02 Suspended eligibility 03 Re-institutionalized 04 Died 05 Moved 06 No longer needed services 07 Other |
8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG153-0001 |
| 3221 | ELG153 | MFP-REASON-PARTICIPATION-ENDED | Not Applicable | NA | If an eligible individual's participation in MFP has ended, then MFP Enrollment End Date cannot be designated as not applicable | Not Applicable | 2/25/2013 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG153-0002 |
| 3222 | ELG154 | MFP-REINSTITUTIONALIZED-REASON | A code describing reason why individual was re-institutionalized after participation in the Money Follows the Person Demonstration. | Conditional | Value must be equal to a valid value. | 00 Default- No MFP 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 |
8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG154-0001 |
| 3223 | ELG155 | MFP-ENROLLMENT-EFF-DATE | The date on which the individual’s participation in the Money Follows the Person Demonstration started. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG155-0001 |
| 3224 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG155-0003 |
| 3225 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG155-0004 |
| 3226 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG155-0005 |
| 3227 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | The MFP-ENROLLMENT-EFF-DATE must occur on or before the MFP-ENROLLMENT-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG155-0006 |
| 3228 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the MFP-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3229 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG155-0007 |
| 3230 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG155-0008 |
| 3231 | ELG155 | MFP-ENROLLMENT-EFF-DATE | Not Applicable | NA | If an individual's restricted benefits status indicated they are entitled to benefits under Money Follows the Person (RESTRICTED-BENEFITS-CODE = "D"), then he/she must have a corresponding MFP enrollment segment with effect and end dates that are within or the same as the effective and end dates of Eligibility Determinant record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3232 | ELG156 | MFP-ENROLLMENT-END-DATE | The date on which the individual’s participation in the Money Follows the Person Demonstration ended. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG156-0001 |
| 3233 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG156-0003 |
| 3234 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG156-0004 |
| 3235 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG156-0005 |
| 3236 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3237 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the MFP-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG156-0006 |
| 3238 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | The MFP-ENROLLMENT-END-DATE must occur on or after the MFP-ENROLLMENT-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3239 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG156-0007 |
| 3240 | ELG156 | MFP-ENROLLMENT-END-DATE | Not Applicable | NA | If an individual's restricted benefits status indicated they are entitled to benefits under Money Follows the Person (RESTRICTED-BENEFITS-CODE = "D"), then he/she must have a corresponding MFP enrollment segment with effect and end dates that are within or the same as the effective and end dates of Eligibility Determinant record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable |
| 3241 | ELG157 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG157-0001 |
| 3242 | ELG157 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG157-0002 |
| 3243 | ELG158 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | MFP-INFORMATION-ELG00010 | ELG158-0001 |
| 3244 | ELG159 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00011 | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG159-0003 |
| 3245 | ELG159 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG159-0001 |
| 3246 | ELG160 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG160-0002 |
| 3247 | ELG160 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG160-0001 |
| 3248 | ELG160 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable |
| 3249 | ELG160 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG160-0003 |
| 3250 | ELG161 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG161-0001 |
| 3251 | ELG161 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG161-0002 |
| 3252 | ELG161 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG161-0003 |
| 3253 | ELG162 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG162-0001 |
| 3254 | ELG162 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG162-0002 |
| 3255 | ELG162 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG162-0003 |
| 3256 | ELG162 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG162-0004 |
| 3257 | ELG162 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable |
| 3258 | ELG162 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable |
| 3259 | ELG162 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG162-0005 |
| 3260 | ELG163 | STATE-PLAN-OPTION-TYPE | This field specifies the State Plan Options in which the individual is enrolled. Use on occurrence for each State Plan Option enrollment. | Conditional | Value must be equal to a valid value. | 00 Not Applicable 01 Community First Choice 02 1915(i) 03 1915(j) 04 1932(a) 05 1915(a) 06 1937 (Alternative Benefit Plans) |
8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG163-0001 |
| 3261 | ELG163 | STATE-PLAN-OPTION-TYPE | Not Applicable | NA | Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE="7" and STATE-PLAN-OPTION-TYPE="06" | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG163-0003 |
| 3262 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | The date on which the individual’s participation in the State Plan Option Type began. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG164-0001 |
| 3263 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG164-0003 |
| 3264 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG164-0004 |
| 3265 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG164-0005 |
| 3266 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | Not Applicable | NA | The STATE-PLAN-OPTION-EFF-DATE must occur on or before the STATE-PLAN-OPTION-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG164-0006 |
| 3267 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the STATE-PLAN-OPTION-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable |
| 3268 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG164-0008 |
| 3269 | ELG164 | STATE-PLAN-OPTION-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG164-0009 |
| 3270 | ELG165 | STATE-PLAN-OPTION-END-DATE | The date on which the individual’s participation in the State Plan Option Type ended. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG165-0001 |
| 3271 | ELG165 | STATE-PLAN-OPTION-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG165-0003 |
| 3272 | ELG165 | STATE-PLAN-OPTION-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG165-0004 |
| 3273 | ELG165 | STATE-PLAN-OPTION-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG165-0005 |
| 3274 | ELG165 | STATE-PLAN-OPTION-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable |
| 3275 | ELG165 | STATE-PLAN-OPTION-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the STATE-PLAN-OPTION-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG165-0006 |
| 3276 | ELG165 | STATE-PLAN-OPTION-END-DATE | Not Applicable | NA | The STATE-PLAN-OPTION-END-DATE must occur on or after the STATE-PLAN-OPTION-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable |
| 3277 | ELG165 | STATE-PLAN-OPTION-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG165-0007 |
| 3278 | ELG166 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG166-0001 |
| 3279 | ELG166 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG166-0002 |
| 3280 | ELG167 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | ELG167-0001 |
| 3281 | ELG168 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00012 | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG168-0003 |
| 3282 | ELG168 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG168-0001 |
| 3283 | ELG169 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG169-0002 |
| 3284 | ELG169 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG169-0001 |
| 3285 | ELG169 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable |
| 3286 | ELG169 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG169-0003 |
| 3287 | ELG170 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG170-0001 |
| 3288 | ELG170 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG170-0002 |
| 3289 | ELG170 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG170-0005 |
| 3290 | ELG171 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG171-0001 |
| 3291 | ELG171 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG171-0002 |
| 3292 | ELG171 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG171-0003 |
| 3293 | ELG171 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG171-0004 |
| 3294 | ELG171 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable |
| 3295 | ELG171 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable |
| 3296 | ELG171 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG171-0005 |
| 3297 | ELG172 | WAIVER-ID | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. The categories of demonstration and waiver programs include: 1915(b)(1); 1915(b)(2); 1915(b)(3), and 1915(b)(4) managed care waivers; 1915(c) home and community based services waivers; combined 1915(b) and 1915(c) managed home and community based services waivers and 1115 demonstrations. | Conditional | Create as many WAIVER-PARTICIPATION (ELG00012) record segments as necessary to record all waivers that are applicable. | Not Applicable | 11/3/2015 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG172-0001 |
| 3298 | ELG172 | WAIVER-ID | Not Applicable | NA | Report the full federal waiver identifier. | Valid values are supplied by the state. | 11/9/2015 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG172-0002 |
| 3299 | ELG172 | WAIVER-ID | Not Applicable | NA | Value must correspond to the WAIVER-TYPE | Not Applicable | 10/10/2013 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG172-0003 |
| 3300 | ELG173 | WAIVER-TYPE | Code for specifying waiver types under which the eligible individual is covered during the month. | Conditional | Enter the WAIVER-TYPE assigned | See Appendix A for listing of valid values. | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG173-0002 |
| 3301 | ELG173 | WAIVER-TYPE | Not Applicable | NA | Value must correspond to associated WAIVER-ID | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable |
| 3302 | ELG173 | WAIVER-TYPE | Not Applicable | NA | If individual was eligible for Medicaid or CHIP but not eligible for a waiver, 8-fill, leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG173-0003 |
| 3303 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Date an individual's enrollment under a particular waiver began. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG174-0001 |
| 3304 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG174-0003 |
| 3305 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG174-0004 |
| 3306 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG174-0005 |
| 3307 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the WAIVER-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable |
| 3308 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | NA | The WAIVER-ENROLLMENT-EFF-DATE must occur on or before the WAIVER-ENROLLMENT-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG174-0006 |
| 3309 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG174-0007 |
| 3310 | ELG174 | WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG174-0008 |
| 3311 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Date an individual's enrollment under a particular waiver ended. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG175-0001 |
| 3312 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG175-0003 |
| 3313 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG175-0004 |
| 3314 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG175-0005 |
| 3315 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable |
| 3316 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the WAIVER-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG175-0006 |
| 3317 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Not Applicable | NA | The WAIVER-ENROLLMENT-END-DATE must occur on or after the WAIVER-ENROLLMENT-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable |
| 3318 | ELG175 | WAIVER-ENROLLMENT-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG175-0007 |
| 3319 | ELG176 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG176-0001 |
| 3320 | ELG176 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG176-0002 |
| 3321 | ELG177 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | ELG177-0001 |
| 3322 | ELG178 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00013 | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG178-0003 |
| 3323 | ELG178 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG178-0001 |
| 3324 | ELG179 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG179-0002 |
| 3325 | ELG179 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG179-0001 |
| 3326 | ELG179 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable |
| 3327 | ELG179 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG179-0003 |
| 3328 | ELG180 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG180-0001 |
| 3329 | ELG180 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG180-0002 |
| 3330 | ELG180 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG180-0003 |
| 3331 | ELG181 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG181-0001 |
| 3332 | ELG181 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG181-0002 |
| 3333 | ELG181 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG181-0003 |
| 3334 | ELG181 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG181-0004 |
| 3335 | ELG181 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable |
| 3336 | ELG181 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable |
| 3337 | ELG181 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG181-0005 |
| 3338 | ELG182 | LTSS-LEVEL-CARE | The level of care provided to the individual by the long term care facility. | Conditional | Value must be equal to a valid value. | 1 Skilled Care 2 Intermediate Care 3 Custodial Care |
8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG182-0001 |
| 3339 | ELG183 | LTSS-PROV-NUM | A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual. | Conditional | Valid formats must be supplied by the state in advance of submitting file data | Valid values are supplied by the state. | 11/3/2015 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG183-0001 |
| 3340 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | The date on which the individual’s eligibility for long term care nursing home service began. (This field should use the onset date of the LTSS eligibility period and not the service span.) This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG184-0001 |
| 3341 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG184-0003 |
| 3342 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG184-0004 |
| 3343 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG184-0005 |
| 3344 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the LTSS-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable |
| 3345 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | NA | The LTSS-ELIGIBILITY-EFF-DATE must occur on or before the LTSS-ELIGIBILITY-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG184-0006 |
| 3346 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG184-0007 |
| 3347 | ELG184 | LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG184-0008 |
| 3348 | ELG185 | LTSS-ELIGIBILITY-END-DATE | The date on which the individual’s eligibility for long term care nursing home service ended. (This field should use the end date of the eligibility period and not the service span.) | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG185-0001 |
| 3349 | ELG185 | LTSS-ELIGIBILITY-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG185-0003 |
| 3350 | ELG185 | LTSS-ELIGIBILITY-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG185-0004 |
| 3351 | ELG185 | LTSS-ELIGIBILITY-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG185-0005 |
| 3352 | ELG185 | LTSS-ELIGIBILITY-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable |
| 3353 | ELG185 | LTSS-ELIGIBILITY-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the LTSS-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG185-0006 |
| 3354 | ELG185 | LTSS-ELIGIBILITY-END-DATE | Not Applicable | NA | The LTSS-ELIGIBILITY-END-DATE must occur on or after the LTSS-ELIGIBILITY-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable |
| 3355 | ELG185 | LTSS-ELIGIBILITY-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG185-0007 |
| 3356 | ELG186 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG186-0001 |
| 3357 | ELG186 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG186-0002 |
| 3358 | ELG187 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | ELG187-0001 |
| 3359 | ELG188 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00014 | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG188-0003 |
| 3360 | ELG188 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG188-0001 |
| 3361 | ELG189 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG189-0002 |
| 3362 | ELG189 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG189-0001 |
| 3363 | ELG189 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3364 | ELG189 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG189-0003 |
| 3365 | ELG190 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG190-0001 |
| 3366 | ELG190 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG190-0002 |
| 3367 | ELG190 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG190-0003 |
| 3368 | ELG191 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG191-0001 |
| 3369 | ELG191 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG191-0002 |
| 3370 | ELG191 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG191-0003 |
| 3371 | ELG191 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG191-0004 |
| 3372 | ELG191 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3373 | ELG191 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3374 | ELG191 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG191-0005 |
| 3375 | ELG192 | MANAGED-CARE-PLAN-ID | The managed care plan identification number under which the eligible individual is enrolled. Use the state’s own identifier. If the state uses the national health plan identifier as its internal number, enter that value in this field as well as the NATIONAL-HEALTH-CARE-ENTITY-ID field. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0001 |
| 3376 | ELG192 | MANAGED-CARE-PLAN-ID | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0002 |
| 3377 | ELG192 | MANAGED-CARE-PLAN-ID | Not Applicable | NA | If individual is not enrolled in any managed care plan, do not report record segment for the individual. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0003 |
| 3378 | ELG192 | MANAGED-CARE-PLAN-ID | Not Applicable | NA | If the MANAGED-CARE-PLAN-ID field is not applicable, then MANAGED-CARE-PLAN-TYPE must be designated as not applicable | Not Applicable | 10/10/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0004 |
| 3379 | ELG192 | MANAGED-CARE-PLAN-ID | Not Applicable | NA | The value reported in this data element must match a STATE-PLAN-ID-NUM value reported on the managed care file and a MANAGED-CARE-PLAN-ID reported on claims files. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0005 |
| 3380 | ELG192 | MANAGED-CARE-PLAN-ID | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File" | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0006 |
| 3381 | ELG192 | MANAGED-CARE-PLAN-ID | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management Reporting" | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0007 |
| 3382 | ELG192 | MANAGED-CARE-PLAN-ID | Not Applicable | NA | A record segment should be reported for each managed care plan ID in which the beneficiary is enrolled | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG192-0008 |
| 3383 | ELG193 | MANAGED-CARE-PLAN-TYPE | A model of health care delivery organized to provide a defined set of services. | Conditional | Must be populated on every record segment |
Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG193-0001 |
| 3384 | ELG193 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | Value must be equal to a valid value. |
See Appendix A for listing of valid values. | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG193-0002 |
| 3385 | ELG193 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | If individual is not enrolled in any managed care plan, do not report record segment for the individual. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG193-0003 |
| 3386 | ELG193 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | The value reported in this data element should match the MANAGED-CARE-PLAN-TYPE value reported on the Managed Care Plan file and claims file for the corresponding managed care plan number | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG193-0006 |
| 3387 | ELG193 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED-CARE-PLAN-TYPE in the T-MSIS Managed Care File" | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG193-0007 |
| 3388 | ELG193 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non‐Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T‐MSIS Managed Care File" | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3389 | ELG194 | NATIONAL-HEALTH-CARE-ENTITY-ID | The national identifier of the health care entity (controlling health plan, subhealth plan, or other entity) at the most granular sub-health plan level of the Medicaid or CHIP health plan in which an individual is enrolled. (See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf ) | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG194-0001 |
| 3390 | ELG194 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | Value must be equal to a valid value. | Not Applicable | 2/25/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG194-0003 |
| 3391 | ELG194 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | This field is required for all eligible persons enrolled in managed care on or after the mandated dates above. | Not Applicable | 2/25/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG194-0004 |
| 3392 | ELG194 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | Field cannot be spaces if MANAGED-CARE-PLAN-TYPE not = '88' or '99' | Not Applicable | 4/30/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG194-0005 |
| 3393 | ELG194 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | If the eligible person is not enrolled in managed care, do not report the segment for the individual | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG194-0006 |
| 3394 | ELG194 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | The NATIONAL-HEALTH-CARE-ENTITY-ID in the eligibility record should match a NATIONAL-HEALTH-CARE-ENTITY-ID on the managed care record for the MANAGED-CARE-PLAN-ID. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3395 | ELG195 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | The NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE distinguishes “controlling” health plan identifiers (CHPIDs), “subhealth” health plan identifiers (SHPIDs), and other entity identifiers (OEIDs) from one another. (See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG195-0001 |
| 3396 | ELG195 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | NA | Value must be in the set of valid values | 1 Controlling Health Plan (CHP) ID 2 Subhealth Plan (SHP) ID 3 Other Entity Identifier (OEID) |
10/10/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG195-0003 |
| 3397 | ELG195 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | NA | If the type HEALTH-CARE-ENTITY-ID-TYPE is unknown, populate the field with a space | Not Applicable | 10/10/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG195-0004 |
| 3398 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | The effective date of an individual's enrollment in a managed care plan. Each instance corresponds to a MANAGED-CARE-PLAN-ID This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG196-0001 |
| 3399 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3400 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG196-0002 |
| 3401 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG196-0004 |
| 3402 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the MANAGED-CARE-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3403 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | NA | The MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE must occur on or before the MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG196-0005 |
| 3404 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG196-0006 |
| 3405 | ELG196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG196-0007 |
| 3406 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | The date an individual's enrollment in a managed care plan ends. Each instance corresponds to a MANAGED-CARE-PLAN-ID | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG197-0001 |
| 3407 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG197-0002 |
| 3408 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG197-0004 |
| 3409 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG197-0005 |
| 3410 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3411 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the MANAGED-CARE-PARTICIPATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG197-0006 |
| 3412 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | NA | The MANAGED-CARE-PLAN-ENROLLMENT-END-DATE must occur on or after the MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable |
| 3413 | ELG197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG197-0007 |
| 3414 | ELG198 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG198-0001 |
| 3415 | ELG198 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG198-0002 |
| 3416 | ELG199 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | ELG199-0001 |
| 3417 | ELG200 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00015 | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG200-0003 |
| 3418 | ELG200 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG200-0001 |
| 3419 | ELG201 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG201-0002 |
| 3420 | ELG201 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG201-0001 |
| 3421 | ELG201 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable |
| 3422 | ELG201 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG201-0003 |
| 3423 | ELG202 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG202-0001 |
| 3424 | ELG202 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG202-0002 |
| 3425 | ELG202 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG202-0003 |
| 3426 | ELG203 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG203-0001 |
| 3427 | ELG203 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG203-0002 |
| 3428 | ELG203 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG203-0003 |
| 3429 | ELG203 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG203-0004 |
| 3430 | ELG203 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable |
| 3431 | ELG203 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable |
| 3432 | ELG203 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG203-0005 |
| 3433 | ELG204 | ETHNICITY-CODE | A code indicating that the individual’s ethnicity is Hispanic, Latino/a, or Spanish. | Conditional | Value must be equal to a valid value. | 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 |
8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG204-0001 |
| 3434 | ELG204 | ETHNICITY-CODE | Not Applicable | NA | ETHNICITY-CODE clarifications: • If state has beneficiaries coded in their database as “Hispanic” or “Latino,” then code them in T-MSIS as “Hispanic or Latino Unknown” (valid value “5”). DO NOT USE “Another Hispanic, Latino, or Spanish Origin,” “Ethnicity Unknown” or “Ethnicity Unspecified.” NOTE 1: The “Ethnicity Unspecified” category in T-MSIS (valid value “6”) should be used with an individual who explicitly did not provide information or refused to answer a question. NOTE 2: The “Ethnicity Unknown” category in T-MSIS (valid value “9”) should be used when there is no information contained / available in the state database about a person’s race, ethnicity, or other category. |
Not Applicable | 9/23/2015 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG204-0002 |
| 3435 | ELG204 | ETHNICITY-CODE | Not Applicable | NA | Use this code to indicate if the eligible’s demographics include an ethnicity of Hispanic or Latino | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG204-0002 |
| 3436 | ELG204 | ETHNICITY-CODE | Not Applicable | NA | This determination is independent of indication of RACE-CODE. | Not Applicable | 2/25/2013 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG204-0003 |
| 3437 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | Code for specifying the type of waiver under which the eligible individual is covered during the coverage period. | NA | The ETHNICITY-DECLARATION-EFF-DATE must occur on or before the ETHNICITY-DECLARATION-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0006 |
| 3438 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | The first day of the time span during which the values in all data elements on an ETHNICITY-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0001 |
| 3439 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0003 |
| 3440 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0004 |
| 3441 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0005 |
| 3442 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the ETHNICITY-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0007 |
| 3443 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0008 |
| 3444 | ELG205 | ETHNICITY-DECLARATION-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG205-0009 |
| 3445 | ELG206 | ETHNICITY-DECLARATION-END-DATE | The last day of the time span during which the values in all data elements on an ETHNICITY-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG206-0001 |
| 3446 | ELG206 | ETHNICITY-DECLARATION-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG206-0003 |
| 3447 | ELG206 | ETHNICITY-DECLARATION-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG206-0004 |
| 3448 | ELG206 | ETHNICITY-DECLARATION-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG206-0005 |
| 3449 | ELG206 | ETHNICITY-DECLARATION-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG206-0006 |
| 3450 | ELG206 | ETHNICITY-DECLARATION-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the ETHNICITY-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG206-0007 |
| 3451 | ELG206 | ETHNICITY-DECLARATION-END-DATE | Not Applicable | NA | The ETHNICITY-DECLARATION-END-DATE must occur on or after the ETHNICITY-DECLARATION-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable |
| 3452 | ELG206 | ETHNICITY-DECLARATION-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG206-0008 |
| 3453 | ELG207 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG207-0001 |
| 3454 | ELG207 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG207-0002 |
| 3455 | ELG208 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | ELG208-0001 |
| 3456 | ELG209 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00016 | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG209-0003 |
| 3457 | ELG209 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG209-0001 |
| 3458 | ELG210 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG210-0002 |
| 3459 | ELG210 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG210-0001 |
| 3460 | ELG210 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable |
| 3461 | ELG210 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG210-0003 |
| 3462 | ELG211 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG211-0001 |
| 3463 | ELG211 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG211-0002 |
| 3464 | ELG211 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG211-0005 |
| 3465 | ELG212 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG212-0001 |
| 3466 | ELG212 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG212-0002 |
| 3467 | ELG212 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG212-0003 |
| 3468 | ELG212 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG212-0004 |
| 3469 | ELG212 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable |
| 3470 | ELG212 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable |
| 3471 | ELG212 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG212-0005 |
| 3472 | ELG213 | RACE | A code indicating the individual’s race either in accordance with requirements of Section 4302 of the Affordable Care Act classifications | Conditional | Value must be in the set of valid values | 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 |
8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG213-0001 |
| 3473 | ELG213 | RACE | Not Applicable | NA | RACE code clarifications: • If state has beneficiaries coded in their database as "Asian” with no additional detail, then code them in T-MSIS as “Asian Unknown” (valid value “011”). DO NOT USE “Other Asian,” “Unspecified” or “Unknown.” • If state has beneficiaries coded in their database as “Native Hawaiian or Other Pacific Islander” with no additional detail, then code them in T-MSIS as “Native Hawaiian and Other Pacific Islander Unknown” (valid value “016”). DO NOT USE “Native Hawaiian,” “Other Pacific Islander,” “Unspecified” or “Unknown.” NOTE 1: The “Other Asian” category in T-MSIS (valid value “010”) should be used in situations in which an individual’s specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese). NOTE 2: The “Unspecified” category in T-MSIS (valid value “017”) should be used with an individual who explicitly did not provide information or refused to answer a question. NOTE 3: The “Unknown” category in T-MSIS (valid value “999”) should be used when there is no information contained / available in the state database about a person’s race, ethnicity, or other category. |
Not Applicable | 9/23/2015 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG213-0002 |
| 3474 | ELG214 | RACE-OTHER | A freeform field to document the race of the beneficiary when the beneficiary identifies themselves as Other Asian, Other Pacific Islander (race codes 010 or 015). | Conditional | Use this field only if the RACE is reported as Other Asian (race code 010) or Other Pacific Islander (race code 015). leave blank or space-fill if not otherwise populated. |
Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG214-0001 |
| 3475 | ELG214 | RACE-OTHER | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG214-0002 |
| 3476 | ELG215 | AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR | “American Indian or Alaska Native” means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR § 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the `Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. • Are you a member of a federally recognized tribe? • Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? |
Conditional | Value must be equal to a valid value. | 0 Individual does not meet the definition of an American Indian/Alaskan Native. 1 Individual meets the definition of an American Indian/Alaskan Native. |
8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG215-0001 |
| 3477 | ELG216 | RACE-DECLARATION-EFF-DATE | The first day of the time span during which the values in all data elements on a RACE-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0001 |
| 3478 | ELG216 | RACE-DECLARATION-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0003 |
| 3479 | ELG216 | RACE-DECLARATION-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0004 |
| 3480 | ELG216 | RACE-DECLARATION-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0005 |
| 3481 | ELG216 | RACE-DECLARATION-EFF-DATE | Not Applicable | NA | The RACE-DECLARATION-EFF-DATE must occur on or before the RACE-DECLARATION-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0006 |
| 3482 | ELG216 | RACE-DECLARATION-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the RACE-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0007 |
| 3483 | ELG216 | RACE-DECLARATION-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0008 |
| 3484 | ELG216 | RACE-DECLARATION-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG216-0009 |
| 3485 | ELG217 | RACE-DECLARATION-END-DATE | The last day of the time span during which the values in all data elements on a RACE-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG217-0001 |
| 3486 | ELG217 | RACE-DECLARATION-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG217-0003 |
| 3487 | ELG217 | RACE-DECLARATION-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG217-0004 |
| 3488 | ELG217 | RACE-DECLARATION-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG217-0005 |
| 3489 | ELG217 | RACE-DECLARATION-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 2/25/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG217-0006 |
| 3490 | ELG217 | RACE-DECLARATION-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the RACE-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG217-0007 |
| 3491 | ELG217 | RACE-DECLARATION-END-DATE | Not Applicable | NA | The RACE-DECLARATION-END-DATE must occur on or after the RACE-DECLARATION-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable |
| 3492 | ELG217 | RACE-DECLARATION-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG217-0008 |
| 3493 | ELG218 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG218-0001 |
| 3494 | ELG218 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG218-0002 |
| 3495 | ELG219 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | RACE-INFORMATION-ELG00016 | ELG219-0001 |
| 3496 | ELG220 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00017 | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG220-0003 |
| 3497 | ELG220 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG220-0001 |
| 3498 | ELG221 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG221-0002 |
| 3499 | ELG221 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG221-0001 |
| 3500 | ELG221 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable |
| 3501 | ELG221 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG221-0003 |
| 3502 | ELG222 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG222-0001 |
| 3503 | ELG222 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG222-0002 |
| 3504 | ELG222 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG222-0003 |
| 3505 | ELG223 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG223-0001 |
| 3506 | ELG223 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG223-0002 |
| 3507 | ELG223 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG223-0003 |
| 3508 | ELG223 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG223-0004 |
| 3509 | ELG223 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable |
| 3510 | ELG223 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable |
| 3511 | ELG223 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG223-0005 |
| 3512 | ELG224 | DISABILITY-TYPE-CODE | A code to identify disability status in accordance with requirements of Section 4302 of the Affordable Care Act. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG224-0001 |
| 3513 | ELG224 | DISABILITY-TYPE-CODE | Not Applicable | NA | Value must be equal to a valid value. | 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 |
8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG224-0002 |
| 3514 | ELG224 | DISABILITY-TYPE-CODE | Not Applicable | NA | Create as many DISABILITY-INFORMATION (ELG00017) record segments as necessary to report all that apply. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG224-0003 |
| 3515 | ELG225 | DISABILITY-TYPE-EFF-DATE | The first day of the time span during which the values in all data elements on a DISABILITY-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0001 |
| 3516 | ELG225 | DISABILITY-TYPE-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0003 |
| 3517 | ELG225 | DISABILITY-TYPE-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0004 |
| 3518 | ELG225 | DISABILITY-TYPE-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0005 |
| 3519 | ELG225 | DISABILITY-TYPE-EFF-DATE | Not Applicable | NA | The DISABILITY-TYPE-EFF-DATE must occur on or before the DISABILITY-TYPE-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0006 |
| 3520 | ELG225 | DISABILITY-TYPE-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the DISABILITY-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0007 |
| 3521 | ELG225 | DISABILITY-TYPE-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0008 |
| 3522 | ELG225 | DISABILITY-TYPE-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG225-0009 |
| 3523 | ELG226 | DISABILITY-TYPE-END-DATE | The last day of the time span during which the values in all data elements on a DISABILITY-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG226-0001 |
| 3524 | ELG226 | DISABILITY-TYPE-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG226-0003 |
| 3525 | ELG226 | DISABILITY-TYPE-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG226-0004 |
| 3526 | ELG226 | DISABILITY-TYPE-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG226-0005 |
| 3527 | ELG226 | DISABILITY-TYPE-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 2/25/2013 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG226-0006 |
| 3528 | ELG226 | DISABILITY-TYPE-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the DISABILITY-INFORMATION record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG226-0007 |
| 3529 | ELG226 | DISABILITY-TYPE-END-DATE | Not Applicable | NA | The DISABILITY-TYPE-END-DATE must occur on or after the DISABILITY-TYPE-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable |
| 3530 | ELG226 | DISABILITY-TYPE-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG226-0008 |
| 3531 | ELG227 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG227-0001 |
| 3532 | ELG227 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG227-0002 |
| 3533 | ELG228 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | ELG228-0001 |
| 3534 | ELG229 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00018 | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG229-0003 |
| 3535 | ELG229 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG229-0001 |
| 3536 | ELG230 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG230-0002 |
| 3537 | ELG230 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG230-0001 |
| 3538 | ELG230 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable |
| 3539 | ELG230 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG230-0003 |
| 3540 | ELG231 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG231-0001 |
| 3541 | ELG231 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG231-0002 |
| 3542 | ELG231 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG231-0003 |
| 3543 | ELG232 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG232-0001 |
| 3544 | ELG232 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG232-0002 |
| 3545 | ELG232 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG232-0003 |
| 3546 | ELG232 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable |
| 3547 | ELG232 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable |
| 3548 | ELG232 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG232-0004 |
| 3549 | ELG232 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG232-0005 |
| 3550 | ELG233 | 1115A-DEMONSTRATION-IND | Indicates that the individual participates in an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. | Conditional | Field is required on all records when state has an active 1115A demonstration. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG233-0001 |
| 3551 | ELG233 | 1115A-DEMONSTRATION-IND | Not Applicable | NA | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG233-0002 |
| 3552 | ELG234 | 1115A-EFF-DATE | The date on which the individual’s participation in 1115A demonstration began. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0001 |
| 3553 | ELG234 | 1115A-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0002 |
| 3554 | ELG234 | 1115A-EFF-DATE | Not Applicable | NA | If individual is NOT enrolled in a CMMI 1115A, do not report the segment for the individual | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0003 |
| 3555 | ELG234 | 1115A-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0004 |
| 3556 | ELG234 | 1115A-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0005 |
| 3557 | ELG234 | 1115A-EFF-DATE | Not Applicable | NA | The 1115A-EFF-DATE must occur on or before the 1115A-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0006 |
| 3558 | ELG234 | 1115A-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0007 |
| 3559 | ELG234 | 1115A-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG234-0008 |
| 3560 | ELG235 | 1115A-END-DATE | The date on which the individual’s participation in 1115A demonstration ended. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0001 |
| 3561 | ELG235 | 1115A-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0002 |
| 3562 | ELG235 | 1115A-END-DATE | Not Applicable | NA | If individual is NOT enrolled in 1115A, do not report segment for the individual | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0003 |
| 3563 | ELG235 | 1115A-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0004 |
| 3564 | ELG235 | 1115A-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0005 |
| 3565 | ELG235 | 1115A-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0006 |
| 3566 | ELG235 | 1115A-END-DATE | Not Applicable | NA | The 1115A-END-DATE must occur on or after the 1115A-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable |
| 3567 | ELG235 | 1115A-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the 1115A-DEMONSTRATION record segment changes, a new record segment must be created | Not Applicable | 10/10/2013 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0007 |
| 3568 | ELG235 | 1115A-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG235-0008 |
| 3569 | ELG236 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG236-0001 |
| 3570 | ELG236 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG236-0002 |
| 3571 | ELG237 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | ELG237-0001 |
| 3572 | ELG238 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00020 | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG238-0003 |
| 3573 | ELG238 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG238-0001 |
| 3574 | ELG239 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG239-0002 |
| 3575 | ELG239 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG239-0001 |
| 3576 | ELG239 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3577 | ELG239 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG239-0003 |
| 3578 | ELG240 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG240-0001 |
| 3579 | ELG240 | RECORD-NUMBER | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG240-0002 |
| 3580 | ELG240 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 2/25/2013 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG240-0003 |
| 3581 | ELG241 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG241-0001 |
| 3582 | ELG241 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG241-0002 |
| 3583 | ELG241 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG241-0003 |
| 3584 | ELG241 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG241-0004 |
| 3585 | ELG241 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3586 | ELG241 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3587 | ELG241 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG241-0005 |
| 3588 | ELG242 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | The chronic condition for which the eligible person is receiving non-Health-Home home and community based care. | Conditional | Value must be equal to a valid value. | 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) |
8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG242-0001 |
| 3589 | ELG243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | The date that the state considers to be the onset date for the eligible person to have the chronic condition. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG243-0001 |
| 3590 | ELG243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3591 | ELG243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3592 | ELG243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 2/25/2013 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG243-0002 |
| 3593 | ELG243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG243-0003 |
| 3594 | ELG243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | Not Applicable | NA | The HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE must occur on or before the HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3595 | ELG243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 10/10/2013 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG243-0004 |
| 3596 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | The last date on which the state considers the eligible person to have the chronic condition. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG244-0001 |
| 3597 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3598 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3599 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG244-0002 |
| 3600 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3601 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements on the HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME record segment changes, a new record segment must be created | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3602 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | NA | The HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE must occur on or after the HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable |
| 3603 | ELG244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG244-0003 |
| 3604 | ELG245 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG245-0001 |
| 3605 | ELG245 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG245-0002 |
| 3606 | ELG246 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | ELG246-0001 |
| 3607 | ELG247 | SEQUENCE-NUMBER | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' SUBMISSION-TRANSACTION-TYPE record files. | Not Applicable | 8/7/2017 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG247-0001 |
| 3608 | ELG247 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | ELG247-0002 |
| 3609 | ELG248 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | ELG00021 | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG248-0003 |
| 3610 | ELG248 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG248-0001 |
| 3611 | ELG249 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG249-0001 |
| 3612 | ELG249 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG249-0002 |
| 3613 | ELG249 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG249-0003 |
| 3614 | ELG249 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG249-0004 |
| 3615 | ELG250 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG250-0001 |
| 3616 | ELG250 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG250-0002 |
| 3617 | ELG250 | RECORD-NUMBER | Not Applicable | NA | Duplicate record number should not exist with in same file | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG250-0003 |
| 3618 | ELG250 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG250-0004 |
| 3619 | ELG251 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG251-0001 |
| 3620 | ELG251 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain a unique identification number assigned by the state. The format of the state MSIS-IDENTIFICATION-NUM must be supplied to CMS with the state's MSIS application. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG251-0002 |
| 3621 | ELG251 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, in instances where the social security number is not known and a temporary MSIS-IDENTIFICATION-NUM is used, the MSIS-IDENTIFICATION-NUM field should be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be space-filled, or blank. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS-IDENTIFICATION-NUM and the SSN field should be populated with the newly acquired social security number for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS-IDENTIFICATION-NUM and the social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG251-0003 |
| 3622 | ELG251 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG251-0004 |
| 3623 | ELG251 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | Non-SSN states must report different values for MSIS-IDENTIFICATION-NUM and SSN. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3624 | ELG251 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Number" for information on reporting MSIS ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS ID | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3625 | ELG251 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | A child record segment must have a parent record segment (PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002). | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG251-0005 |
| 3626 | ELG252 | ENROLLMENT-TYPE | Identify the type of enrollment that the eligible person has been enrolled into as either Medicaid/Medicaid Expansion CHIP or Separate CHIP. | Required | Value must be equal to a valid value. | 1 Medicaid or Medicaid Expansion CHIP 2 Separate Title XXI CHIP |
8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG252-0001 |
| 3627 | ELG252 | ENROLLMENT-TYPE | Not Applicable | NA | This data element must be completed for every individual enrolled in the State's Medicaid or CHIP program. | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG252-0002 |
| 3628 | ELG252 | ENROLLMENT-TYPE | Not Applicable | NA | A beneficiary reported with a CHIP-CODE value of "1" or "2" should be reported with an ENROLLMENT-TYPE of "1" for the same period of enrollment. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG252-0003 |
| 3629 | ELG252 | ENROLLMENT-TYPE | Not Applicable | NA | A beneficiary reported with a CHIP-CODE value of "3" should be reported with an ENROLLMENT-TYPE of "2" for the same period of enrollment. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG252-0004 |
| 3630 | ELG253 | ENROLLMENT-EFF-DATE | The first day of enrollment for the ENROLLMENT-TYPE and MSIS-IDENTIFICATION-NUM being reported in the ENROLLMENT-TIME-SPAN-SEGMENT record segment. This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG253-0001 |
| 3631 | ELG253 | ENROLLMENT-EFF-DATE | Not Applicable | NA | If a complete, valid effective date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3632 | ELG253 | ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG253-0002 |
| 3633 | ELG253 | ENROLLMENT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG253-0003 |
| 3634 | ELG253 | ENROLLMENT-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the ENROLLMENT-TIME-SPAN-SEGMENT record segment changes, a new record segment must be created. | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG253-0004 |
| 3635 | ELG253 | ENROLLMENT-EFF-DATE | Not Applicable | NA | Overlapping coverage for a given combination of key fields (as specified in the Record Segment Keys and Constraints guidance document) not allowed for same file segment | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3636 | ELG253 | ENROLLMENT-EFF-DATE | Not Applicable | NA | The ENROLLMENT-EFF-DATE must occur on or before the ENROLLMENT-END-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG253-0005 |
| 3637 | ELG253 | ENROLLMENT-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3638 | ELG254 | ENROLLMENT-END-DATE | The last day of enrollment for the ENROLLMENT-TYPE and MSIS-IDENTIFICATION-NUM being reported in the ENROLLMENT-TIME-SPAN-SEGMENT record segment. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG254-0001 |
| 3639 | ELG254 | ENROLLMENT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3640 | ELG254 | ENROLLMENT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG254-0002 |
| 3641 | ELG254 | ENROLLMENT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG254-0003 |
| 3642 | ELG254 | ENROLLMENT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3643 | ELG254 | ENROLLMENT-END-DATE | Not Applicable | NA | The ENROLLMENT-END-DATE must occur on or after the ENROLLMENT-EFF-DATE | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3644 | ELG254 | ENROLLMENT-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the ENROLLMENT-TIME-SPAN-SEGMENT record segment changes, a new record segment must be created. | Not Applicable | 10/10/2013 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG254-0004 |
| 3645 | ELG254 | ENROLLMENT-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable |
| 3646 | ELG255 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG255-0001 |
| 3647 | ELG255 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG255-0002 |
| 3648 | ELG256 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | ELG256-0001 |
| 3649 | MCR001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | MCR00001 | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR001-0003 |
| 3650 | MCR001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR001-0001 |
| 3651 | MCR002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR002-0001 |
| 3652 | MCR003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR003-0002 |
| 3653 | MCR003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR003-0001 |
| 3654 | MCR004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or delimited format. | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR004-0002 |
| 3655 | MCR005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR005-0001 |
| 3656 | MCR006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR006-0001 |
| 3657 | MCR006 | FILE-NAME | Not Applicable | NA | Value must be equal to a valid value. | MNGDCARE Managed Care Plan Information file | 10/10/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR006-0002 |
| 3658 | MCR007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR007-0002 |
| 3659 | MCR007 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR007-0001 |
| 3660 | MCR007 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR007-0003 |
| 3661 | MCR007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable |
| 3662 | MCR008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Required on every file header | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR008-0001 |
| 3663 | MCR008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR008-0002 |
| 3664 | MCR008 | DATE-FILE-CREATED | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR008-0003 |
| 3665 | MCR008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR008-0004 |
| 3666 | MCR009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR009-0002 |
| 3667 | MCR009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR009-0001 |
| 3668 | MCR009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR009-0003 |
| 3669 | MCR009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable |
| 3670 | MCR009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR009-0006 |
| 3671 | MCR009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR009-0005 |
| 3672 | MCR010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR010-0001 |
| 3673 | MCR010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR010-0002 |
| 3674 | MCR010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR010-0003 |
| 3675 | MCR010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR010-0004 |
| 3676 | MCR010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR010-0005 |
| 3677 | MCR010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than DATE-FILE-CREATED. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable |
| 3678 | MCR010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or greater than START-OF-TIME-PERIOD. | Not Applicable | 2/25/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR010-0006 |
| 3679 | MCR011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR011-0001 |
| 3680 | MCR011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR011-0002 |
| 3681 | MCR011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable |
| 3682 | MCR012 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR012-0001 |
| 3683 | MCR013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR013-0001 |
| 3684 | MCR013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR013-0002 |
| 3685 | MCR014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR014-0001 |
| 3686 | MCR014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR014-0002 |
| 3687 | MCR016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | MCR00002 | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR016-0003 |
| 3688 | MCR016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR016-0001 |
| 3689 | MCR017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR017-0002 |
| 3690 | MCR017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR017-0001 |
| 3691 | MCR017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR017-0003 |
| 3692 | MCR017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR017-0004 |
| 3693 | MCR018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR018-0001 |
| 3694 | MCR018 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR018-0002 |
| 3695 | MCR018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR018-0003 |
| 3696 | MCR019 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR019-0001 |
| 3697 | MCR019 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR019-0002 |
| 3698 | MCR019 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR019-0004 |
| 3699 | MCR019 | STATE-PLAN-ID-NUM | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management Reporting" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR019-0005 |
| 3700 | MCR020 | MANAGED-CARE-CONTRACT-EFF-DATE | The start date of the managed care contract period with the state. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR020-0001 |
| 3701 | MCR020 | MANAGED-CARE-CONTRACT-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3702 | MCR020 | MANAGED-CARE-CONTRACT-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR020-0002 |
| 3703 | MCR020 | MANAGED-CARE-CONTRACT-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR020-0003 |
| 3704 | MCR020 | MANAGED-CARE-CONTRACT-EFF-DATE | Not Applicable | NA | The MANAGED-CARE-CONTRACT-EFF-DATE must occur on or before the MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3705 | MCR021 | MANAGED-CARE-CONTRACT-END-DATE | The expiration date of the managed care contract period with the state. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR021-0001 |
| 3706 | MCR021 | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3707 | MCR021 | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3708 | MCR021 | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR021-0002 |
| 3709 | MCR021 | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR021-0003 |
| 3710 | MCR021 | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR021-0004 |
| 3711 | MCR021 | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | NA | The MANAGED-CARE-CONTRACT-END-DATE must occur on or after the MANAGED-CARE-CONTRACT-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR021-0005 |
| 3712 | MCR022 | MANAGED-CARE-NAME | The name of the managed care entity under contract with the State Medicaid Agency. The name should be as it appears on the contract. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR022-0001 |
| 3713 | MCR022 | MANAGED-CARE-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR022-0002 |
| 3714 | MCR023 | MANAGED-CARE-PROGRAM | The state program through which a managed care plan is approved to operate. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR023-0001 |
| 3715 | MCR023 | MANAGED-CARE-PROGRAM | Not Applicable | NA | Value must be equal to a valid value. | 1 Medicaid State Plan 2 CHIP State Plan 3 Both Medicaid and CHIP |
10/10/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR023-0002 |
| 3716 | MCR024 | MANAGED-CARE-PLAN-TYPE | The type of managed care plan that corresponds to the STATE-PLAN-ID-NUM. | Required | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR024-0001 |
| 3717 | MCR024 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | Value must be equal to a valid value. |
See Appendix A for listing of valid values. | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR024-0002 |
| 3718 | MCR024 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | Left fill with zeros if number is less than 2 bytes long. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR024-0003 |
| 3719 | MCR024 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | Assign plan type value "15" for plans that primarily cover non-emergency medical transportation (NEMT) | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR024-0004 |
| 3720 | MCR024 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non‐Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T‐MSIS Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR024-0005 |
| 3721 | MCR024 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED-CARE-PLAN-TYPE in the T-MSIS Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR024-0006 |
| 3722 | MCR024 | MANAGED-CARE-PLAN-TYPE | Not Applicable | NA | The value reported in this data element should match the MANAGED-CARE-PLAN-TYPE value reported on the Eligible file for the corresponding managed care plan number | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR024-0007 |
| 3723 | MCR025 | REIMBURSEMENT-ARRANGEMENT | A code indicating the how the managed care entity is reimbursed. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR025-0001 |
| 3724 | MCR025 | REIMBURSEMENT-ARRANGEMENT | Not Applicable | NA | Value must be equal to a valid value. | 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 |
8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR025-0002 |
| 3725 | MCR026 | MANAGED-CARE-PROFIT-STATUS | A code denoting the profit status of managed care entity. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR026-0001 |
| 3726 | MCR026 | MANAGED-CARE-PROFIT-STATUS | Not Applicable | NA | Value must be equal to a valid value. | 01 501(C)(3) NON-PROFIT 02 FOR-PROFIT, CLOSELY HELD 03 FOR-PROFIT, PUBLICLY TRADED 04 OTHER |
8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR026-0002 |
| 3727 | MCR026 | MANAGED-CARE-PROFIT-STATUS | Not Applicable | NA | Left fill with zeros if number is less than 2 bytes long. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR026-0003 |
| 3728 | MCR027 | CORE-BASED-STATISTICAL-AREA-CODE | A code signifying whether the Managed Care Organization's (MCO) service area falls into one or more metropolitan or micropolitan statistical areas. Metropolitan and micropolitan statistical areas (metro and micro areas) are geographic entities defined by the U.S. Office of Management and Budget (OMB). The term "Core Based Statistical Area" (CBSA) is a collective term for both metro and micro areas. A metro area contains a core urban area of 50,000 or more population, and a micro area contains an urban core of at least 10,000 (but less than 50,000) population. Each metro or micro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core. The U.S. Office of Management and Budget (OMB) defines metropolitan or micropolitan statistical areas based on published standards. The standards for defining the areas are reviewed and revised once every ten years, prior to each decennial census. Between censuses, the definitions are updated annually to reflect the most recent Census Bureau population estimates. The current definitions are as of December 2009. See the hyperlink below for further information. http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf | Required | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR027-0001 |
| 3729 | MCR027 | CORE-BASED-STATISTICAL-AREA-CODE | Not Applicable | NA | Value must be equal to a valid value. | 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. |
8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR027-0002 |
| 3730 | MCR027 | CORE-BASED-STATISTICAL-AREA-CODE | Not Applicable | NA | Whenever a service area straddles two types of areas (e.g., metropolitan & micropolitan, metropolitan & non-CBSA area) classify the service area based on the denser classification. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR027-0003 |
| 3731 | MCR028 | PERCENT-BUSINESS | The percentage of the managed care entity’s total revenue that is derived from contracts with Medicare (Part C and D) in the state and State Medicaid agency contract(s) prior calendar year. Include Medicaid and Medicare in calculation of percentage of business in public programs for IRS health insurer tax exemption as required in ACA. | Required | Enter a percent of 0 through 100. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR028-0001 |
| 3732 | MCR028 | PERCENT-BUSINESS | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR028-0002 |
| 3733 | MCR029 | MANAGED-CARE-SERVICE-AREA | Identifies the geographic unit under which the managed care entity is under contract to provide services. | Required | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR029-0001 |
| 3734 | MCR029 | MANAGED-CARE-SERVICE-AREA | Not Applicable | NA | Value must be equal to a valid value. | 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. |
10/10/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR029-0002 |
| 3735 | MCR029 | MANAGED-CARE-SERVICE-AREA | Not Applicable | NA | The value reported in MANAGED-CARE-SERVICE-AREA should represent the geographical unit of the values reported in the MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR029-0003 |
| 3736 | MCR029 | MANAGED-CARE-SERVICE-AREA | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED‐CARE‐SERVICE‐AREA in the Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR029-0004 |
| 3737 | MCR030 | MANAGED-CARE-MAIN-REC-EFF-DATE | The first day of the time span during which the values in all data elements in the MANAGED-CARE-MAIN record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR030-0001 |
| 3738 | MCR030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3739 | MCR030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR030-0002 |
| 3740 | MCR030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3741 | MCR030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the MANAGED-CARE-MAIN record segment changes, a new record segment must be created. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3742 | MCR030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR030-0003 |
| 3743 | MCR030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Not Applicable | NA | The MANAGED-CARE-MAIN-REC-EFF-DATE must occur on or before the MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR030-0004 |
| 3744 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | The last day of the time span during which the values in all data elements in the MANAGED-CARE-MAIN record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR031-0001 |
| 3745 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR031-0002 |
| 3746 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR031-0003 |
| 3747 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3748 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable |
| 3749 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | NA | The MANAGED-CARE-MAIN-REC-END-DATE must occur on or after the MANAGED-CARE-MAIN-REC-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR031-0004 |
| 3750 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state & Plan ID | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR031-0005 |
| 3751 | MCR031 | MANAGED-CARE-MAIN-REC-END-DATE | Not Applicable | NA | Managed Care coverage dates must be within Managed Care Contract Date | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR031-0006 |
| 3752 | MCR032 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR032-0001 |
| 3753 | MCR032 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR032-0002 |
| 3754 | MCR033 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | MCR033-0001 |
| 3755 | MCR034 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | MCR00003 | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR034-0003 |
| 3756 | MCR034 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR034-0001 |
| 3757 | MCR035 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR035-0002 |
| 3758 | MCR035 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR035-0001 |
| 3759 | MCR035 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR035-0003 |
| 3760 | MCR035 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR035-0004 |
| 3761 | MCR036 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR036-0001 |
| 3762 | MCR036 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR036-0002 |
| 3763 | MCR036 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR036-0003 |
| 3764 | MCR037 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR037-0001 |
| 3765 | MCR037 | STATE-PLAN-ID-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR037-0002 |
| 3766 | MCR037 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR037-0003 |
| 3767 | MCR037 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR037-0004 |
| 3768 | MCR038 | MANAGED-CARE-LOCATION-ID | A field to differentiate a managed care entity’s service locations through adding a sequential number in this data element identifier field. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR038-0001 |
| 3769 | MCR038 | MANAGED-CARE-LOCATION-ID | Not Applicable | NA | Each of an managed care entity’s locations must have a unique MANAGED-CARE-LOCATION-ID | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR038-0002 |
| 3770 | MCR038 | MANAGED-CARE-LOCATION-ID | Not Applicable | NA | This data element should be populated if MANAGED-CARE-ADDR-TYPE is 3 (Managed care entity’s service location address) | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR038-0003 |
| 3771 | MCR038 | MANAGED-CARE-LOCATION-ID | Not Applicable | NA | Use sequential numbers to indicate additional services locations | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR038-0004 |
| 3772 | MCR038 | MANAGED-CARE-LOCATION-ID | Not Applicable | NA | Right-fill the field if the value is less than 15 bytes long. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR038-0005 |
| 3773 | MCR039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | The first day of the time span during which the values in all data elements in the MANAGED-CARE-LOCATION-AND-CONTACT-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR039-0001 |
| 3774 | MCR039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR039-0002 |
| 3775 | MCR039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR039-0003 |
| 3776 | MCR039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR039-0004 |
| 3777 | MCR039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | The MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE must occur on or before the MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable |
| 3778 | MCR039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable |
| 3779 | MCR039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the MANAGED-CARE-LOCATION-AND-CONTACT-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR039-0005 |
| 3780 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | The last day of the time span during which the values in all data elements in the MANAGED-CARE-LOCATION-AND-CONTACT-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0001 |
| 3781 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0002 |
| 3782 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable |
| 3783 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable |
| 3784 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0003 |
| 3785 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0004 |
| 3786 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | The MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE must occur on or after the MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0005 |
| 3787 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Overlapping date spans should not exist for a given combination of state/state plan ID/Location ID/Address Type | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0006 |
| 3788 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0007 |
| 3789 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Active MANAGED-CARE-MAIN record must exist in T-MSIS database or contained in the current submission for each record with a MANAGED-CARE-LOCATION-AND-CONTACT-INFO segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0008 |
| 3790 | MCR040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the MANAGED-CARE-LOCATION-AND-CONTACT-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR040-0009 |
| 3791 | MCR041 | MANAGED-CARE-ADDR-TYPE | A code to distinguish various addresses that a managed care entity may have. | Required | This data element must be populated on every MANAGED-CARE-LOCATION-AND-CONTACT-INFO record. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR041-0001 |
| 3792 | MCR041 | MANAGED-CARE-ADDR-TYPE | Not Applicable | NA | Value must be equal to a valid value. | 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 |
10/10/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR041-0002 |
| 3793 | MCR042 | MANAGED-CARE-ADDR-LN1 | The managed care entity’s address listed on the contract with the state. | Required | Line 1 is required. Lines 2 through 3 can be blank. | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR042-0001 |
| 3794 | MCR042 | MANAGED-CARE-ADDR-LN1 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR042-0002 |
| 3795 | MCR043 | MANAGED-CARE-ADDR-LN2 | The managed care entity’s address listed on the contract with the state. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR043-0001 |
| 3796 | MCR043 | MANAGED-CARE-ADDR-LN2 | Not Applicable | NA | Line 1 is required. Lines 2 through 3 can be blank. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR043-0002 |
| 3797 | MCR043 | MANAGED-CARE-ADDR-LN2 | Not Applicable | NA | When this data element is not populated or used, States must completely 8-fill, 9-fill, space-fill, or blank-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR043-0003 |
| 3798 | MCR044 | MANAGED-CARE-ADDR-LN3 | The managed care entity’s address listed on the contract with the state. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR044-0001 |
| 3799 | MCR044 | MANAGED-CARE-ADDR-LN3 | Not Applicable | NA | Line 1 is required. Lines 2 through 3 can be blank. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR044-0002 |
| 3800 | MCR044 | MANAGED-CARE-ADDR-LN3 | Not Applicable | NA | When this data element is not populated or used, States must completely 8-fill, 9-fill, space-fill, or blank-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR044-0003 |
| 3801 | MCR045 | MANAGED-CARE-CITY | The city of the managed care entity’s address as listed on the contract with the state. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR045-0001 |
| 3802 | MCR045 | MANAGED-CARE-CITY | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR045-0002 |
| 3803 | MCR046 | MANAGED-CARE-STATE | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the of the managed care entity’s address as listed on the contract with the state. | Required | Value must be equal to a valid value. | http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR046-0001 |
| 3804 | MCR047 | MANAGED-CARE-ZIP-CODE | The zip code of the managed care entity as it appears in the address listed on the contract with the state. | Required | Must be populated on every record | Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR047-0001 |
| 3805 | MCR047 | MANAGED-CARE-ZIP-CODE | Not Applicable | NA | The value must consist of digits 0 through 9 only | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR047-0002 |
| 3806 | MCR047 | MANAGED-CARE-ZIP-CODE | Not Applicable | NA | First 5 bytes (i.e., the 5-digit zip code) is required | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable |
| 3807 | MCR047 | MANAGED-CARE-ZIP-CODE | Not Applicable | NA | If the four-digit extension is available, that may be filled in using the last four byes. Otherwise, if the last 4 digits are not populated or used, then the 4-digit extended zip code should be recorded as “0000”. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR047-0003 |
| 3808 | MCR048 | MANAGED-CARE-COUNTY | The ANSI County numeric code for the county or county equivalent. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR048-0001 |
| 3809 | MCR048 | MANAGED-CARE-COUNTY | Not Applicable | NA | Value must be numeric. | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR048-0002 |
| 3810 | MCR048 | MANAGED-CARE-COUNTY | Not Applicable | NA | Value must be equal to a valid value. | http://www.census.gov/geo/reference/codes/countylookup.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR048-0003 |
| 3811 | MCR048 | MANAGED-CARE-COUNTY | Not Applicable | NA | One county code should be captured for each of a managed care entity’s locations (MANAGED-CARE-LOCATION-IDs). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR048-0004 |
| 3812 | MCR049 | MANAGED-CARE-TELEPHONE | The telephone number, including area code, of the managed care entity as listed on the contract with the state. | Optional | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR049-0001 |
| 3813 | MCR049 | MANAGED-CARE-TELEPHONE | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR049-0002 |
| 3814 | MCR049 | MANAGED-CARE-TELEPHONE | Not Applicable | NA | Enter the digits only (i.e., without parentheses, brackets, dashes, periods, spaces, etc.) | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR049-0003 |
| 3815 | MCR050 | MANAGED-CARE-EMAIL | The email address of the managed care entity as listed on the contract with the state. | Optional | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR050-0001 |
| 3816 | MCR050 | MANAGED-CARE-EMAIL | Not Applicable | NA | Must contain @ | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR050-0002 |
| 3817 | MCR050 | MANAGED-CARE-EMAIL | Not Applicable | NA | Must have [email protected] format | Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR050-0003 |
| 3818 | MCR051 | MANAGED-CARE-FAX-NUMBER | A fax number, including area code, as listed on the contract with the state | Optional | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR051-0001 |
| 3819 | MCR051 | MANAGED-CARE-FAX-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR051-0002 |
| 3820 | MCR051 | MANAGED-CARE-FAX-NUMBER | Not Applicable | NA | Enter the digits only (i.e., without parentheses, brackets, dashes, periods, spaces, etc.) | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR051-0003 |
| 3821 | MCR052 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR052-0001 |
| 3822 | MCR052 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR052-0002 |
| 3823 | MCR053 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | MCR053-0001 |
| 3824 | MCR054 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | MCR00004 | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR054-0003 |
| 3825 | MCR054 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR054-0001 |
| 3826 | MCR055 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR055-0002 |
| 3827 | MCR055 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR055-0001 |
| 3828 | MCR055 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR055-0003 |
| 3829 | MCR055 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR055-0004 |
| 3830 | MCR056 | RECORD-NUMBER | Beginning date of the time period covered by this file. | Required | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR056-0001 |
| 3831 | MCR056 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR056-0002 |
| 3832 | MCR056 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR056-0003 |
| 3833 | MCR057 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR057-0001 |
| 3834 | MCR057 | STATE-PLAN-ID-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR057-0002 |
| 3835 | MCR057 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR057-0003 |
| 3836 | MCR057 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR057-0004 |
| 3837 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | The specific identifiers for the counties, cities, regions, zip codes and/or other geographic areas that the managed care entity serves. | Required | Value must be equal to a valid value. | http://www.census.gov/geo/reference/ansi.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0001 |
| 3838 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | NA | If Managed-care-service-area is 2, 3, 4, 5, or 6 create/submit a MANAGED-CARE-SERVICE-AREA record for each service area. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0002 |
| 3839 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | NA | Use ANSI county codes when service area is defined by counties or cities. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0003 |
| 3840 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | NA | Put each zip code, city, county, region, or other area descriptor on a separate record. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0004 |
| 3841 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | NA | Use 5 digit zip codes when service area definition is zip code based. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0005 |
| 3842 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0006 |
| 3843 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | NA | The value reported in MANAGED-CARE-SERVICE-AREA should represent the geographical unit of the values reported in the MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0007 |
| 3844 | MCR058 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED‐CARE‐SERVICE‐AREA in the Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR058-0008 |
| 3845 | MCR059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | The first day of the time span during which the values in all data elements in the MANAGED-CARE-SERVICE-AREA record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR059-0001 |
| 3846 | MCR059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR059-0002 |
| 3847 | MCR059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR059-0003 |
| 3848 | MCR059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR059-0004 |
| 3849 | MCR059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable |
| 3850 | MCR059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Not Applicable | NA | The MANAGED-CARE-SERVICE-AREA-EFF-DATE must occur on or before the MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable |
| 3851 | MCR059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the MANAGED-CARE-SERVICE-AREA record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR059-0005 |
| 3852 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | The last day of the time span during which the values in all data elements in the MANAGED-CARE-SERVICE-AREA record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0001 |
| 3853 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0002 |
| 3854 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0003 |
| 3855 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable |
| 3856 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231) | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable |
| 3857 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0004 |
| 3858 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | The MANAGED-CARE-SERVICE-AREA-END-DATE must occur on or after the MANAGED-CARE-SERVICE-AREA-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0005 |
| 3859 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | Overlapping date spans should not exist for a given combination of state/state plan ID/Service Area Name | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0006 |
| 3860 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0007 |
| 3861 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | Active MANAGED-CARE-MAIN record must exist in T-MSIS database or contained in the current submission for each record with a MANAGED-CARE-LOCATION-AND-CONTACT-INFO segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0008 |
| 3862 | MCR060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the MANAGED-CARE-SERVICE-AREA record segment changes, a new record segment must be created | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR060-0009 |
| 3863 | MCR061 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR061-0001 |
| 3864 | MCR061 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR061-0002 |
| 3865 | MCR062 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | MCR062-0001 |
| 3866 | MCR063 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | MCR00005 | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR063-0003 |
| 3867 | MCR063 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR063-0001 |
| 3868 | MCR064 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR064-0002 |
| 3869 | MCR064 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR064-0001 |
| 3870 | MCR064 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR064-0003 |
| 3871 | MCR064 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR064-0004 |
| 3872 | MCR065 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR065-0001 |
| 3873 | MCR065 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR065-0002 |
| 3874 | MCR065 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR065-0003 |
| 3875 | MCR066 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR066-0001 |
| 3876 | MCR066 | STATE-PLAN-ID-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR066-0002 |
| 3877 | MCR066 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR066-0003 |
| 3878 | MCR066 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR066-0004 |
| 3879 | MCR067 | OPERATING-AUTHORITY | The type of operating authority through which the managed care entity receives its contract authority. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR067-0001 |
| 3880 | MCR067 | OPERATING-AUTHORITY | Not Applicable | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 2/25/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR067-0002 |
| 3881 | MCR067 | OPERATING-AUTHORITY | Not Applicable | NA | Fill in the Operating Authority under which the plan is operating. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR067-0003 |
| 3882 | MCR067 | OPERATING-AUTHORITY | Not Applicable | NA | The MANAGED-CARE-PLAN-TYPE assigned to the manage care plan in the MANAGED-CARE-MAIN segment should be consistent with the OPERATING-AUTHORITY value reported. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR067-0004 |
| 3883 | MCR067 | OPERATING-AUTHORITY | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED-CARE-PLAN-TYPE in the T-MSIS Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR067-0005 |
| 3884 | MCR068 | WAIVER-ID | Field specifying the ID of the waiver, demonstration or other authority which authorizes the state to operate the managed care program. These IDs must be the approved, full federal ID number assigned during the state submission and CMS approval process. | Required | Report the full federal waiver identifier. The renewal number suffix and amendment number suffix do not need to be reported as part of the 1915(b) waiver IDs. |
Valid values are supplied by the state. | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR068-0001 |
| 3885 | MCR068 | WAIVER-ID | Not Applicable | NA | The value reported in this data element should match the WAIVER-ID value reported on the Eligible file. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable |
| 3886 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | The original program implementation date provided by the authority. This date field is necessary when defining a unique row in a database table. |
Required | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR069-0001 |
| 3887 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR069-0002 |
| 3888 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR069-0003 |
| 3889 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR069-0004 |
| 3890 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable |
| 3891 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the MANAGED-CARE-OPERATING-AUTHORITY record segment changes, a new record segment must be created. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable |
| 3892 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | NA | The MANAGED-CARE-OP-AUTHORITY-EFF-DATE must occur on or before the MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR069-0005 |
| 3893 | MCR069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED‐CARE‐OP‐AUTHORITY‐EFF/END‐ DATE in the T‐MSIS Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR069-0006 |
| 3894 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | The date that the state authority to operate their managed care program ends. For active managed care programs, the value reported in this field is established as the future end date in the operating authority documents. | Required | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0001 |
| 3895 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0002 |
| 3896 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable |
| 3897 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0003 |
| 3898 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0004 |
| 3899 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | The MANAGED-CARE-OP-AUTHORITY-END-DATE must occur on or after the MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0005 |
| 3900 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | For active managed care programs without end date, the value reported in this field should be "99991231". | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable |
| 3901 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | Overlapping date spans should not exist for a given combination of state/state plan ID/Operating Authority/Waiver ID | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0006 |
| 3902 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0007 |
| 3903 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | Active MANAGED-CARE-MAIN record must exist in T-MSIS database or contained in the current submission for each record with a MANAGED-CARE-LOCATION-AND-CONTACT-INFO segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0008 |
| 3904 | MCR070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED‐CARE‐OP‐AUTHORITY‐EFF/END‐ DATE in the T‐MSIS Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR070-0009 |
| 3905 | MCR071 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR071-0001 |
| 3906 | MCR071 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR071-0002 |
| 3907 | MCR072 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | MCR072-0001 |
| 3908 | MCR073 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | MCR00006 | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR073-0003 |
| 3909 | MCR073 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR073-0001 |
| 3910 | MCR074 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR074-0002 |
| 3911 | MCR074 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR074-0001 |
| 3912 | MCR074 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR074-0003 |
| 3913 | MCR074 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR074-0004 |
| 3914 | MCR075 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR075-0001 |
| 3915 | MCR075 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR075-0002 |
| 3916 | MCR075 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR075-0003 |
| 3917 | MCR076 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR076-0001 |
| 3918 | MCR076 | STATE-PLAN-ID-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR076-0002 |
| 3919 | MCR076 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR076-0003 |
| 3920 | MCR076 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR076-0004 |
| 3921 | MCR077 | MANAGED-CARE-PLAN-POP | The eligibility group(s) the state is authorized to enroll in managed care plans by its operating authority. | Required | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR077-0001 |
| 3922 | MCR077 | MANAGED-CARE-PLAN-POP | Not Applicable | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR077-0002 |
| 3923 | MCR077 | MANAGED-CARE-PLAN-POP | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR077-0003 |
| 3924 | MCR077 | MANAGED-CARE-PLAN-POP | Not Applicable | NA | Submit a separate record segment for each eligibility group that can be enrolled in the managed care program in which the managed care plan is participating. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR077-0004 |
| 3925 | MCR078 | MANAGED-CARE-PLAN-POP-EFF-DATE | The date from which the authorized populations can be enrolled in managed care plans contracted under the managed care program. This date field is necessary when defining a unique row in a database table. |
Required | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR078-0001 |
| 3926 | MCR078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR078-0002 |
| 3927 | MCR078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable |
| 3928 | MCR078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR078-0003 |
| 3929 | MCR078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Not Applicable | NA | The MANAGED-CARE-PLAN-POP-EFF-DATE must occur on or before the MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable |
| 3930 | MCR078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the MANAGED-CARE-PLAN-POPULATION-ENROLLED record segment changes, a new record segment must be created. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable |
| 3931 | MCR078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR078-0004 |
| 3932 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | The date after which the authorized populations cannot be enrolled in managed care plans contracted under the managed care program. | Required | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0001 |
| 3933 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0002 |
| 3934 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable |
| 3935 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | For active managed care programs without end date, the value reported in this field should be "99991231". | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable |
| 3936 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0003 |
| 3937 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0004 |
| 3938 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | The MANAGED-CARE-PLAN-POP-END-DATE must occur on or after the MANAGED-CARE-PLAN-POP-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0005 |
| 3939 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | Overlapping date spans should not exist for a given combination of state/state plan ID/managed care plan pop | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0006 |
| 3940 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0007 |
| 3941 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | Active MANAGED-CARE-MAIN record must exist in T-MSIS database or contained in the current submission for each record with a MANAGED-CARE-LOCATION-AND-CONTACT-INFO segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0008 |
| 3942 | MCR079 | MANAGED-CARE-PLAN-POP-END-DATE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED‐CARE‐PLAN‐POP in the T‐MSIS Managed Care File" | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR079-0009 |
| 3943 | MCR080 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR080-0001 |
| 3944 | MCR080 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR080-0002 |
| 3945 | MCR081 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | MCR081-0001 |
| 3946 | MCR082 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | MCR00007 | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR082-0003 |
| 3947 | MCR082 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR082-0001 |
| 3948 | MCR083 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR083-0002 |
| 3949 | MCR083 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR083-0001 |
| 3950 | MCR083 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR083-0003 |
| 3951 | MCR083 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR083-0004 |
| 3952 | MCR084 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR084-0001 |
| 3953 | MCR084 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR084-0002 |
| 3954 | MCR084 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR084-0003 |
| 3955 | MCR085 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR085-0001 |
| 3956 | MCR085 | STATE-PLAN-ID-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR085-0002 |
| 3957 | MCR085 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR085-0003 |
| 3958 | MCR085 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR085-0004 |
| 3959 | MCR086 | ACCREDITATION-ORGANIZATION | Identify the accreditation awarded to the managed care entity. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR086-0001 |
| 3960 | MCR086 | ACCREDITATION-ORGANIZATION | Not Applicable | NA | Value must be equal to a valid value. | 01 National committee for quality assurance – excellent 02 National committee for quality assurance – commendable 03 National committee for quality assurance – provisional 05 URAC - full 06 URAC - conditional 07 URAC – provisional 08 Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) – 3 years 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 |
9/23/2015 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR086-0002 |
| 3961 | MCR087 | DATE-ACCREDITATION-ACHIEVED | The date the organization achieved accreditation. This date field is necessary when defining a unique row in a database table. |
Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR087-0001 |
| 3962 | MCR087 | DATE-ACCREDITATION-ACHIEVED | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR087-0002 |
| 3963 | MCR087 | DATE-ACCREDITATION-ACHIEVED | Not Applicable | NA | The date must be a valid date. | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR087-0003 |
| 3964 | MCR087 | DATE-ACCREDITATION-ACHIEVED | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR087-0004 |
| 3965 | MCR087 | DATE-ACCREDITATION-ACHIEVED | Not Applicable | NA | Date must be equal to or less than DATE-ACCREDITATION-END | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR087-0005 |
| 3966 | MCR088 | DATE-ACCREDITATION-END | The date when organization’s accreditation ends. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR088-0001 |
| 3967 | MCR088 | DATE-ACCREDITATION-END | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR088-0002 |
| 3968 | MCR088 | DATE-ACCREDITATION-END | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR088-0003 |
| 3969 | MCR088 | DATE-ACCREDITATION-END | Not Applicable | NA | Date must be equal to or less than DATE-ACCREDITATION-ACHIEVED | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR088-0004 |
| 3970 | MCR088 | DATE-ACCREDITATION-END | Not Applicable | NA | Overlapping date spans should not exist for a given combination of state/state plan ID/accreditation organization | Not Applicable | 10/10/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR088-0005 |
| 3971 | MCR088 | DATE-ACCREDITATION-END | Not Applicable | NA | Coverage span date must be fully contained within in the set of effective date spans of all active parent records | Not Applicable | 4/30/2013 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR088-0006 |
| 3972 | MCR088 | DATE-ACCREDITATION-END | Not Applicable | NA | Active MANAGED-CARE-MAIN record must exist in T-MSIS database or contained in the current submission for each record with a MANAGED-CARE-LOCATION-AND-CONTACT-INFO segment | Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR088-0007 |
| 3973 | MCR089 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR089-0001 |
| 3974 | MCR089 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR089-0002 |
| 3975 | MCR090 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | MCR090-0001 |
| 3976 | MCR091 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | NA | Value must be equal to a valid value. NOTE: Adoption of the national health plan identifiers (HPIDs) and other entity identifiers (OEIDs) as described in the final rule HHS published on 2012-09-05 is on indefinite hold. As a result, T-MSIS record segments MCR00008 and MCR00009 are not applicable and do not need to be submitted until further notice. States that are generating "dummy" segments in accordance with earlier CMS guidance may continue to do so if they so choose. |
MCR00008 | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR091-0001 |
| 3977 | MCR091 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR091-0003 |
| 3978 | MCR092 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | NA | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR092-0002 |
| 3979 | MCR092 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR092-0001 |
| 3980 | MCR092 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR092-0003 |
| 3981 | MCR092 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR092-0004 |
| 3982 | MCR093 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | NA | Must be populated on every record | Not Applicable | 10/10/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR093-0001 |
| 3983 | MCR093 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR093-0002 |
| 3984 | MCR093 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR093-0003 |
| 3985 | MCR094 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | NA | Must be populated on every record | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR094-0001 |
| 3986 | MCR094 | STATE-PLAN-ID-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR094-0002 |
| 3987 | MCR094 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR094-0003 |
| 3988 | MCR094 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR094-0004 |
| 3989 | MCR095 | NATIONAL-HEALTH-CARE-ENTITY-ID | The national health plan identifier(s) or other entity identifier(s) assigned to a managed care entity in accordance with 45 CFR 162 Subpart E. All of the entity’s national health care entity identifiers should be reported using the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO and CHPID-SHPID-RELATIONSHIPS record segments. | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR095-0001 |
| 3990 | MCR095 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR095-0002 |
| 3991 | MCR095 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | This field is required for all managed care plans that are covered entities on or after the mandated dates above. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR095-0004 |
| 3992 | MCR095 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | National identifiers in the eligible file must match either a controlling health plan (CHP) identifier or subhealth plan (SHP) identifier in the Managed Care subject area. | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR095-0005 |
| 3993 | MCR096 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | The NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE distinguishes “controlling” health plan identifiers (CHPIDs), “subhealth” health plan identifiers (SHPIDs), and other entity identifiers (OEIDs) from one another. See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | 1 Controlling Health Plan (CHP) ID 2 Subhealth Plan (SHP) ID 3 Other Entity Identifier (OEID) |
8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR096-0001 |
| 3994 | MCR097 | NATIONAL-HEALTH-CARE-ENTITY-NAME | The legal name of the health care entity identified by the corresponding value in the NATIONAL-HEALTH-CARE-ENTITY-ID field. | NA | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR097-0001 |
| 3995 | MCR097 | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR097-0002 |
| 3996 | MCR097 | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | NA | Use the descriptive name assigned by the state as it exists in the state’s MMIS. | Not Applicable | 9/23/2015 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR097-0003 |
| 3997 | MCR097 | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | NA | If there is no name associated with the NATIONAL-HEALTH-CARE-ENTITY-ID in the state’s MMIS, the field should be space-filled, or blank. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR097-0004 |
| 3998 | MCR098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | The first day of the time span during which the values in all data elements in the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
NA | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR098-0001 |
| 3999 | MCR098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR098-0002 |
| 4000 | MCR098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR098-0003 |
| 4001 | MCR098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR098-0004 |
| 4002 | MCR098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | NA | The NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE must occur on or before the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR098-0006 |
| 4003 | MCR098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable |
| 4004 | MCR098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR098-0007 |
| 4005 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | The first day of the time span during which the values in all data elements in the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | NA | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0001 |
| 4006 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0002 |
| 4007 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0003 |
| 4008 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0004 |
| 4009 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable |
| 4010 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | For active managed care programs without end date, the value reported in this field should be "99991231". | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable |
| 4011 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | The NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE must occur on or after the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0005 |
| 4012 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | Overlapping date spans should not exist for a given combination of state/state plan ID/ National Health Care Entity ID/National Health Care Entity ID type | Not Applicable | 10/10/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0006 |
| 4013 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0007 |
| 4014 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | Active MANAGED-CARE-MAIN record must exist in T-MSIS database or contained in the current submission for each record with a MANAGED-CARE-LOCATION-AND-CONTACT-INFO segment | Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0008 |
| 4015 | MCR099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR099-0009 |
| 4016 | MCR100 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR100-0002 |
| 4017 | MCR100 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR100-0001 |
| 4018 | MCR101 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | MCR101-0001 |
| 4019 | MCR102 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | NA | Value must be equal to a valid value. NOTE: Adoption of the national health plan identifiers (HPIDs) and other entity identifiers (OEIDs) as described in the final rule HHS published on 2012-09-05 is on indefinite hold. As a result, T-MSIS record segments MCR00008 and MCR00009 are not applicable and do not need to be submitted until further notice. States that are generating "dummy" segments in accordance with earlier CMS guidance may continue to do so if they so choose. |
MCR00009 | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR102-0003 |
| 4020 | MCR102 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR102-0001 |
| 4021 | MCR103 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | NA | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR103-0002 |
| 4022 | MCR103 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR103-0001 |
| 4023 | MCR103 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR103-0003 |
| 4024 | MCR103 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR103-0004 |
| 4025 | MCR104 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | NA | Must be populated on every record | Not Applicable | 10/10/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR104-0001 |
| 4026 | MCR104 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 2/25/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR104-0002 |
| 4027 | MCR104 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR104-0003 |
| 4028 | MCR105 | STATE-PLAN-ID-NUM | Contains the ID number the state issued to the managed care entity. | NA | Must be populated on every record | Not Applicable | 2/25/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR105-0001 |
| 4029 | MCR105 | STATE-PLAN-ID-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 2/25/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR105-0002 |
| 4030 | MCR105 | STATE-PLAN-ID-NUM | Not Applicable | NA | STATE-PLAN-ID-NUM must match a STATE-PLAN-ID-NUM on the MANAGED-CARE-MAIN segment | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR105-0003 |
| 4031 | MCR105 | STATE-PLAN-ID-NUM | Not Applicable | NA | If the National Health Plan Identifier is available, enter the number in this field and the NATIONAL-HEALTH-CARE-ENTITY-ID field. If not available, enter the state’s internal plan ID. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR105-0004 |
| 4032 | MCR106 | CHPID | A data element to capture the Controlling Health Plan Identifier (CHPID) on the CHPID-SHPID-RELATIONSHIPS record. The CHPID-SHPID-RELATIONSHIPS record links a controlling health plan with its associated sub-health plans. (Sub-health plans are identified by SHPIDs.) |
NA | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR106-0001 |
| 4033 | MCR106 | CHPID | Not Applicable | NA | Every CHPID must have an associated active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO segment. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR106-0002 |
| 4034 | MCR107 | SHPID | A data element to capture the Subhealth Plan Identifier (SHPID) on the CHPID-SHPID-RELATIONSHIPS record. The CHPID-SHPID-RELATIONSHIPS records link controlling health plans with their associated sub-health plans. (Controlling health plans are identified by CHPIDs.) |
NA | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR107-0001 |
| 4035 | MCR107 | SHPID | Not Applicable | NA | Every SHPID must have an associated active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO segment. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR107-0002 |
| 4036 | MCR108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | The first day that the state submitting the CHPID-SHPID-RELATIONSHIPS record segment considers the data therein to be valid and active. The purpose of the effective and end dates on the CHPID-SHPID-RELATIONSHIPS record segment is to permit the submitting state show the span of time during which they consider the CHP ID to SHP ID relationship to be valid. This date field is necessary when defining a unique row in a database table. |
NA | Must be populated on every record | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR108-0001 |
| 4037 | MCR108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR108-0002 |
| 4038 | MCR108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR108-0003 |
| 4039 | MCR108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR108-0004 |
| 4040 | MCR108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the CHPID-SHPID-RELATIONSHIPS record segment changes, a new record segment must be created. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable |
| 4041 | MCR108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable |
| 4042 | MCR108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | NA | The CHPID-SHPID-RELATIONSHIP-EFF-DATE must occur on or before the CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR108-0006 |
| 4043 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | The last day that the state submitting the CHPID-SHPID-RELATIONSHIPS record segment considers the data therein to be valid and active. The purpose of the effective & end dates on the CHPID-SHPID-RELATIONSHIPS record segment is to permit the submitting state show the span of time during which they consider the CHP ID to SHP ID relationship to be valid. |
NA | Must be populated on every record | Not Applicable | 11/3/2015 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0001 |
| 4044 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0002 |
| 4045 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0003 |
| 4046 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0004 |
| 4047 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | The CHPID-SHPID-RELATIONSHIP-END-DATE must occur on or after the CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0005 |
| 4048 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | Overlapping date spans should not exist for a given combination of state/state plan ID/CHPID/SHPID | Not Applicable | 10/10/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0006 |
| 4049 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0007 |
| 4050 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | Active MANAGED-CARE-MAIN and NATIONAL-HEALTH-CARE-ENTITY-ID-INFO record must exist in T-MSIS database or contained in the current submission for each plan with a CHPID-SHPID-RELATIONSHIPS segment. | Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0008 |
| 4051 | MCR109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 2/25/2013 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR109-0009 |
| 4052 | MCR110 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR110-0001 |
| 4053 | MCR110 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR110-0002 |
| 4054 | MCR111 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | MCR111-0001 |
| 4055 | MCR112 | SEQUENCE-NUMBER | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' SUBMISSION-TRANSACTION-TYPE record files. | Not Applicable | 8/7/2017 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR112-0001 |
| 4056 | MCR112 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | MCR112-0002 |
| 4057 | PRV001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00001 | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV001-0001 |
| 4058 | PRV001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV001-0002 |
| 4059 | PRV002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV002-0001 |
| 4060 | PRV003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV003-0001 |
| 4061 | PRV003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV003-0002 |
| 4062 | PRV004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or delimited format. | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV004-0001 |
| 4063 | PRV005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document | Not Applicable | 2/25/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV005-0001 |
| 4064 | PRV006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Required on every file header record | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV006-0001 |
| 4065 | PRV006 | FILE-NAME | Not Applicable | NA | Value must be equal to a valid value. | PROVIDER - Provider file |
4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV006-0002 |
| 4066 | PRV007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV007-0001 |
| 4067 | PRV007 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV007-0002 |
| 4068 | PRV007 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV007-0003 |
| 4069 | PRV007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV007-0004 |
| 4070 | PRV008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV008-0001 |
| 4071 | PRV008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV008-0002 |
| 4072 | PRV008 | DATE-FILE-CREATED | Not Applicable | NA | Required on every file header | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV008-0003 |
| 4073 | PRV008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV008-0004 |
| 4074 | PRV009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV009-0001 |
| 4075 | PRV009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV009-0003 |
| 4076 | PRV009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV009-0002 |
| 4077 | PRV009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV009-0005 |
| 4078 | PRV009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV009-0006 |
| 4079 | PRV009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV009-0004 |
| 4080 | PRV010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. |
Required | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV010-0001 |
| 4081 | PRV010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV010-0002 |
| 4082 | PRV010 | END-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV010-0003 |
| 4083 | PRV010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV010-0004 |
| 4084 | PRV010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than DATE-FILE-CREATED. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable |
| 4085 | PRV010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or greater than START-OF-TIME-PERIOD. | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV010-0005 |
| 4086 | PRV010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable |
| 4087 | PRV011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV011-0001 |
| 4088 | PRV011 | FILE-STATUS-INDICATOR | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV011-0002 |
| 4089 | PRV011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 4/30/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV011-0003 |
| 4090 | PRV012 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV012-0001 |
| 4091 | PRV013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV013-0001 |
| 4092 | PRV013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV013-0002 |
| 4093 | PRV014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV014-0001 |
| 4094 | PRV014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV014-0002 |
| 4095 | PRV016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00002 | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV016-0001 |
| 4096 | PRV016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV016-0002 |
| 4097 | PRV017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV017-0001 |
| 4098 | PRV017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV017-0002 |
| 4099 | PRV017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV017-0003 |
| 4100 | PRV017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV017-0004 |
| 4101 | PRV018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV018-0001 |
| 4102 | PRV018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV018-0003 |
| 4103 | PRV019 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV019-0001 |
| 4104 | PRV019 | SUBMITTING-STATE-PROV-ID | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting SUBMITTING-STATE-PROVIDER-ID in the T-MSIS Provider File" | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV019-0002 |
| 4105 | PRV020 | PROV-ATTRIBUTES-EFF-DATE | The first day of the time span during which the values in all data elements in the PROV-ATTRIBUTES-MAIN record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV020-0001 |
| 4106 | PRV020 | PROV-ATTRIBUTES-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV020-0002 |
| 4107 | PRV020 | PROV-ATTRIBUTES-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV020-0003 |
| 4108 | PRV020 | PROV-ATTRIBUTES-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV020-0004 |
| 4109 | PRV020 | PROV-ATTRIBUTES-EFF-DATE | Not Applicable | NA | The PROV-ATTRIBUTES-EFF-DATE must occur on or before the PROV-ATTRIBUTES-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable |
| 4110 | PRV020 | PROV-ATTRIBUTES-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable |
| 4111 | PRV020 | PROV-ATTRIBUTES-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-ATTRIBUTES-MAIN record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV020-0005 |
| 4112 | PRV021 | PROV-ATTRIBUTES-END-DATE | The last day of the time span during which the values in all data elements in the PROV-ATTRIBUTES-MAIN record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV021-0001 |
| 4113 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV021-0002 |
| 4114 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable |
| 4115 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable |
| 4116 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV021-0003 |
| 4117 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | The PROV-ATTRIBUTES-END-DATE must occur on or after the PROV-ATTRIBUTES-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV021-0004 |
| 4118 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-ATTRIBUTES-MAIN record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV021-0005 |
| 4119 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable |
| 4120 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state, Submitting state provider ID, and Record ID. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV021-0006 |
| 4121 | PRV021 | PROV-ATTRIBUTES-END-DATE | Not Applicable | NA | The Date must be less than or equal to DATE-OF-DEATH | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV021-0007 |
| 4122 | PRV022 | PROV-DOING-BUSINESS-AS-NAME | The provider’s name that is commonly used by the public when the “doing-business-as” (`) name is different than the legal name. DBA is an abbreviation for "doing business as." Registering a DBA is required to operate a business under a name that differs from the company's legal name. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV022-0001 |
| 4123 | PRV022 | PROV-DOING-BUSINESS-AS-NAME | Not Applicable | NA | Leave the field empty when the DBA name equals the legal name (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV022-0002 |
| 4124 | PRV022 | PROV-DOING-BUSINESS-AS-NAME | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV022-0003 |
| 4125 | PRV023 | PROV-LEGAL-NAME | The name as it appears on the provider agreement between the state and the entity. Both persons and other entities can have a legal name. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV023-0001 |
| 4126 | PRV023 | PROV-LEGAL-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV023-0002 |
| 4127 | PRV023 | PROV-LEGAL-NAME | Not Applicable | NA | Every provider is expected to have a legal name. When the data element is not populated or used, the data element should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files). | Not Applicable | 9/23/2015 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV023-0003 |
| 4128 | PRV023 | PROV-LEGAL-NAME | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV023-0004 |
| 4129 | PRV024 | PROV-ORGANIZATION-NAME | The name of the provider when the provider is an organization. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV024-0001 |
| 4130 | PRV024 | PROV-ORGANIZATION-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV024-0002 |
| 4131 | PRV024 | PROV-ORGANIZATION-NAME | Not Applicable | NA | Provider Organization Name should be same as last name when provider is an individual | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV024-0003 |
| 4132 | PRV024 | PROV-ORGANIZATION-NAME | Not Applicable | NA | Enter the first 60 characters if the provider organization name exceeds 60 characters Enter the first 35 characters if the last name exceeds 35 bytes |
Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV024-0004 |
| 4133 | PRV024 | PROV-ORGANIZATION-NAME | Not Applicable | NA | Use PROV-LAST-NAME when the provider is an individual. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV024-0005 |
| 4134 | PRV024 | PROV-ORGANIZATION-NAME | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV024-0006 |
| 4135 | PRV025 | PROV-TAX-NAME | The name that the provider entity uses on IRS filings. | Required | Must be populated on every record. | Not Applicable | 9/23/2015 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV025-0001 |
| 4136 | PRV025 | PROV-TAX-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV025-0002 |
| 4137 | PRV025 | PROV-TAX-NAME | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV025-0003 |
| 4138 | PRV026 | FACILITY-GROUP-INDIVIDUAL-CODE | A code to identify whether the SUBMITTING-STATE-PROV-ID is assigned to an individual, a group of providers, or a facility. | Required | Value must be equal to a valid value. | 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. |
4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV026-0001 |
| 4139 | PRV026 | FACILITY-GROUP-INDIVIDUAL-CODE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV026-0002 |
| 4140 | PRV026 | FACILITY-GROUP-INDIVIDUAL-CODE | Not Applicable | NA | Every SUBMITTING-STATE-PROV-ID must be classified using the codes in the valid values list |
Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV026-0003 |
| 4141 | PRV027 | TEACHING-IND | A code indicating if the provider’s organization is a teaching facility. | Conditional | Value must be equal to a valid value. | 0 No 1 Yes |
8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV027-0001 |
| 4142 | PRV027 | TEACHING-IND | Not Applicable | NA | TEACHING-IND should be reported with a value of "0" if the provider is an individual or a practice group. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable |
| 4143 | PRV027 | TEACHING-IND | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV027-0002 |
| 4144 | PRV028 | PROV-FIRST-NAME | The first name of the provider when the provider is a person. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV028-0001 |
| 4145 | PRV028 | PROV-FIRST-NAME | Not Applicable | NA | Leave blank when the provider is not an individual. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV028-0002 |
| 4146 | PRV028 | PROV-FIRST-NAME | Not Applicable | NA | Enter the first 35 characters if the first name exceeds 35 bytes | Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV028-0003 |
| 4147 | PRV029 | PROV-MIDDLE-INITIAL | The middle initial of the provider when the provider is a person. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV029-0001 |
| 4148 | PRV029 | PROV-MIDDLE-INITIAL | Not Applicable | NA | Leave blank if not available |
Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV029-0002 |
| 4149 | PRV029 | PROV-MIDDLE-INITIAL | Not Applicable | NA | Leave blank when the provider is not an individual. | Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV029-0003 |
| 4150 | PRV030 | PROV-LAST-NAME | The last name of the provider when the provider is a person. Use PROV-ORGANIZATION-NAME when the provider is an organization. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV030-0001 |
| 4151 | PRV030 | PROV-LAST-NAME | Not Applicable | NA | Leave blank when the provider is not an individual. | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV030-0002 |
| 4152 | PRV030 | PROV-LAST-NAME | Not Applicable | NA | Enter the first 35 characters if the first name exceeds 35 bytes | Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV030-0003 |
| 4153 | PRV030 | PROV-LAST-NAME | Not Applicable | NA | If the provider is an organization, populate the provider organization name using the PROV-ORGANIZATION-NAME data element | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV030-0004 |
| 4154 | PRV031 | SEX | The individual’s biological sex. | Conditional | If populated, the value must be in the list of valid values. | F Female M Male U Unknown |
4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV031-0001 |
| 4155 | PRV031 | SEX | Not Applicable | NA | Must be populated when provider is an individual | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV031-0002 |
| 4156 | PRV032 | OWNERSHIP-CODE | A code denoting the ownership interest and/or managing control information. The valid values list is a Medicare standard list. | Required | Value must be equal to a valid value. | 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 |
10/10/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV032-0001 |
| 4157 | PRV032 | OWNERSHIP-CODE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV032-0002 |
| 4158 | PRV033 | PROV-PROFIT-STATUS | A code denoting the profit status of the provider. | Required | Value must be equal to a valid value. | 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 |
8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV033-0001 |
| 4159 | PRV034 | DATE-OF-BIRTH | Date of birth of the provider. Applicable to individual providers only. | Conditional | Must be populated when provider is an individual | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV034-0001 |
| 4160 | PRV034 | DATE-OF-BIRTH | Not Applicable | NA | Date format is CCYYMMDD (National Data Standard). |
Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV034-0002 |
| 4161 | PRV034 | DATE-OF-BIRTH | Not Applicable | NA | Date must be less than or equal to current date | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV034-0003 |
| 4162 | PRV035 | DATE-OF-DEATH | Date of death of the provider, if applicable. Applicable to individual providers only. | Conditional | Date format is CCYYMMDD (National Data Standard). |
Not Applicable | 2/25/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0001 |
| 4163 | PRV035 | DATE-OF-DEATH | Not Applicable | Conditional | The date must be a valid date. | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0002 |
| 4164 | PRV035 | DATE-OF-DEATH | Not Applicable | NA | Date of Death is greater than 0 when provider is not an individual | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0003 |
| 4165 | PRV035 | DATE-OF-DEATH | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0004 |
| 4166 | PRV035 | DATE-OF-DEATH | Not Applicable | NA | Date is less than DATE-OF-BIRTH | Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0005 |
| 4167 | PRV035 | DATE-OF-DEATH | Not Applicable | NA | A provider with a date of death before the submission should not be listed as a health home provider for an eligible individual. | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0006 |
| 4168 | PRV035 | DATE-OF-DEATH | Not Applicable | NA | A provider with a date of death before the submission should not be listed as a lockin provider for an eligible individual. | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0007 |
| 4169 | PRV035 | DATE-OF-DEATH | Not Applicable | NA | Value must be equal to a valid value. | Not Applicable | 4/30/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV035-0008 |
| 4170 | PRV036 | ACCEPTING-NEW-PATIENTS-IND | An indicator to identify providers who are accepting new patients | Required | Value must be equal to a valid value. | 0 No 1 Yes 8 N/A – The individual only practices as a member of a group. |
10/10/2013 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV036-0001 |
| 4171 | PRV037 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV037-0001 |
| 4172 | PRV037 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV037-0002 |
| 4173 | PRV038 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | PRV038-0001 |
| 4174 | PRV039 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00003 | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV039-0001 |
| 4175 | PRV039 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV039-0002 |
| 4176 | PRV040 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV040-0001 |
| 4177 | PRV040 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV040-0002 |
| 4178 | PRV040 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV040-0003 |
| 4179 | PRV040 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV040-0004 |
| 4180 | PRV041 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV041-0001 |
| 4181 | PRV041 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV041-0002 |
| 4182 | PRV042 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV042-0001 |
| 4183 | PRV043 | PROV-LOCATION-ID | A code to uniquely identify the geographic locations where the provider performs services. These codes will also be reported in the PROV-LOCATION-ID field on CLAIM-HEADER-RECORD-IP, -LT, -OT, and –RX record segments | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV043-0001 |
| 4184 | PRV043 | PROV-LOCATION-ID | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV043-0002 |
| 4185 | PRV043 | PROV-LOCATION-ID | Not Applicable | NA | Each of a provider entity’s locations must have a unique PROV-LOCATION-ID | Not Applicable | 2/25/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV043-0003 |
| 4186 | PRV043 | PROV-LOCATION-ID | Not Applicable | NA | If a particular license is applicable to all locations, use the value ‘000’ value to represent ‘all’ locations. | Not Applicable | 9/23/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV043-0004 |
| 4187 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | The first day of the time span during which the values in all data elements in the PROV-LOCATION-AND-CONTACT-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV044-0001 |
| 4188 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV044-0002 |
| 4189 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV044-0003 |
| 4190 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV044-0004 |
| 4191 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Must be equal to or less than end date | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV044-0005 |
| 4192 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | The PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE must occur on or before the PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable |
| 4193 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable |
| 4194 | PRV044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LOCATION-AND-CONTACT-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV044-0006 |
| 4195 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | The last day of the time span during which the values in all data elements in the PROV-LOCATION-AND-CONTACT-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0001 |
| 4196 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0002 |
| 4197 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable |
| 4198 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable |
| 4199 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0003 |
| 4200 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0004 |
| 4201 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LOCATION-AND-CONTACT-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0005 |
| 4202 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | The PROV-LOCATION-AND-CONTACT-INFO-END-DATE must occur on or after the PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0006 |
| 4203 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state & Prov ID, Location ID, Address Type | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0007 |
| 4204 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0008 |
| 4205 | PRV045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV045-0009 |
| 4206 | PRV046 | ADDR-TYPE | The type of address that is stored in the remaining address fields. The data elements in the PROV-LOCATION-AND-CONTACT-INFO record are intended to capture the physical address and other contact information related to a provider. Each PROV-LOCATION-AND-CONTACT-INFO record represents the set of contact information for a single provider location. |
Required | Value must be equal to a valid value. | 1 Billing Provider 2 Provider Mailing 3 Provider Practice 4 Provider Service Location |
2/25/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV046-0001 |
| 4207 | PRV046 | ADDR-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV046-0002 |
| 4208 | PRV046 | ADDR-TYPE | Not Applicable | NA | The state can enter as many sets of contact information (i.e., multiple PROV-LOCATION-AND-CONTACT-INFO records) as it considers necessary. The value selected for the ADDR-TYPE field describes the type of contact information on that particular record (e.g., provider service location, provider billing address, etc.). The PROV-LOCATION-ID differentiates one PROV-LOCATION-AND-CONTACT-INFO record from another when the ADDR-TYPE value on both records is the same. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV046-0003 |
| 4209 | PRV047 | ADDR-LN1 | The street address, including the street name, street number, and room/suite number or letter, for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. |
Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV047-0001 |
| 4210 | PRV047 | ADDR-LN1 | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV047-0002 |
| 4211 | PRV047 | ADDR-LN1 | Not Applicable | NA | Line 1 is required and the other two lines can be blank. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV047-0003 |
| 4212 | PRV048 | ADDR-LN2 | The street address, including the street name, street number, and room/suite number or letter, for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV048-0001 |
| 4213 | PRV048 | ADDR-LN2 | Not Applicable | NA | The data elements in the PROV-LOCATION-AND-CONTACT-INFO record are intended to capture the physical address and other contact information related to a provider. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV048-0002 |
| 4214 | PRV048 | ADDR-LN2 | Not Applicable | NA | Each PROV-LOCATION-AND-CONTACT-INFO record represents the set of contact information for a single provider location. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV048-0003 |
| 4215 | PRV048 | ADDR-LN2 | Not Applicable | NA | The state can enter as many sets of contact information (i.e., multiple PROV-LOCATION-AND-CONTACT-INFO records) as it considers necessary. The value selected for the ADDR-TYPE field describes the type of contact information on that particular record (e.g., provider service location, provider billing address, etc.). The PROV-LOCATION-ID differentiates one PROV-LOCATION-AND-CONTACT-INFO record from another when the ADDR-TYPE value on both records is the same. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV048-0004 |
| 4216 | PRV048 | ADDR-LN2 | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV048-0005 |
| 4217 | PRV049 | ADDR-LN3 | The street address, including the street name, street number, and room/suite number or letter, for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. |
Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV049-0001 |
| 4218 | PRV049 | ADDR-LN3 | Not Applicable | NA | The third line of the address must not be the same as the first or second line of the address (if applicable) | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV049-0002 |
| 4219 | PRV049 | ADDR-LN3 | Not Applicable | NA | The data elements in the PROV-LOCATION-AND-CONTACT-INFO record are intended to capture the physical address and other contact information related to a provider. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV049-0003 |
| 4220 | PRV049 | ADDR-LN3 | Not Applicable | NA | Each PROV-LOCATION-AND-CONTACT-INFO record represents the set of contact information for a single provider location. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV049-0004 |
| 4221 | PRV049 | ADDR-LN3 | Not Applicable | NA | The state can enter as many sets of contact information (i.e., multiple PROV-LOCATION-AND-CONTACT-INFO records) as it considers necessary. The value selected for the ADDR-TYPE field describes the type of contact information on that particular record (e.g., provider service location, provider billing address, etc.). The PROV-LOCATION-ID differentiates one PROV-LOCATION-AND-CONTACT-INFO record from another when the ADDR-TYPE value on both records is the same. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV049-0005 |
| 4222 | PRV049 | ADDR-LN3 | Not Applicable | NA | When this data element is not populated or used, States must leave blank or space-fill these elements in accordance to the S2TM Addendum C, in both fixed-length and pipe-delimited files. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV049-0006 |
| 4223 | PRV050 | ADDR-CITY | The city name for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. |
Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV050-0001 |
| 4224 | PRV050 | ADDR-CITY | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV050-0002 |
| 4225 | PRV050 | ADDR-CITY | Not Applicable | NA | The data elements in the PROV-LOCATION-AND-CONTACT-INFO record are intended to capture the physical address and other contact information related to a provider. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV050-0003 |
| 4226 | PRV050 | ADDR-CITY | Not Applicable | NA | Each PROV-LOCATION-AND-CONTACT-INFO record represents the set of contact information for a single provider location. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV050-0004 |
| 4227 | PRV050 | ADDR-CITY | Not Applicable | NA | The state can enter as many sets of contact information (i.e., multiple PROV-LOCATION-AND-CONTACT-INFO records) as it considers necessary. The value selected for the ADDR-TYPE field describes the type of contact information on that particular record (e.g., provider service location, provider billing address, etc.). The PROV-LOCATION-ID differentiates one PROV-LOCATION-AND-CONTACT-INFO record from another when the ADDR-TYPE value on both records is the same. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV050-0005 |
| 4228 | PRV051 | ADDR-STATE | The two letter ANSI state numeric code for each U.S. state, territory, and the District of Columbia for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. |
Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV051-0001 |
| 4229 | PRV051 | ADDR-STATE | Not Applicable | NA | Value must be equal to a valid value. | http://www.census.gov/geo/reference/ansi_statetables.html | 10/10/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV051-0002 |
| 4230 | PRV051 | ADDR-STATE | Not Applicable | NA | The data elements in the PROV-LOCATION-AND-CONTACT-INFO record are intended to capture the physical address and other contact information related to a provider. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV051-0003 |
| 4231 | PRV051 | ADDR-STATE | Not Applicable | NA | Each PROV-LOCATION-AND-CONTACT-INFO record represents the set of contact information for a single provider location. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV051-0004 |
| 4232 | PRV051 | ADDR-STATE | Not Applicable | NA | The state can enter as many sets of contact information (i.e., multiple PROV-LOCATION-AND-CONTACT-INFO records) as it considers necessary. The value selected for the ADDR-TYPE field describes the type of contact information on that particular record (e.g., provider service location, provider billing address, etc.). The PROV-LOCATION-ID differentiates one PROV-LOCATION-AND-CONTACT-INFO record from another when the ADDR-TYPE value on both records is the same. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV051-0005 |
| 4233 | PRV052 | ADDR-ZIP-CODE | The Zip Code for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. |
Required | Value must be numeric | Not Applicable | 9/23/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV052-0001 |
| 4234 | PRV052 | ADDR-ZIP-CODE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV052-0002 |
| 4235 | PRV052 | ADDR-ZIP-CODE | Not Applicable | NA | If the last 4 digits are not populated or used, then the 4-digit extended zip code should be recorded as “0000”. | Not Applicable | 9/23/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV052-0003 |
| 4236 | PRV053 | ADDR-TELEPHONE | The telephone number for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. |
Optional | Enter the digits only (i.e., without parentheses, brackets, dashes, periods, spaces, etc.) | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV053-0001 |
| 4237 | PRV053 | ADDR-TELEPHONE | Not Applicable | NA | Must be populated on every record | Not Applicable | 11/3/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV053-0002 |
| 4238 | PRV053 | ADDR-TELEPHONE | Not Applicable | NA | Value must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV053-0003 |
| 4239 | PRV053 | ADDR-TELEPHONE | Not Applicable | NA | Enter 10-digit telephone number (includes area code) | Not Applicable | 2/25/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV053-0004 |
| 4240 | PRV053 | ADDR-TELEPHONE | Not Applicable | NA | If unknown,leave blank or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV053-0005 |
| 4241 | PRV054 | ADDR-EMAIL | The email address of the provider for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record |
Optional | Must contain @ | Not Applicable | 11/3/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV054-0001 |
| 4242 | PRV054 | ADDR-EMAIL | Not Applicable | NA | Must have [email protected] format | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV054-0002 |
| 4243 | PRV055 | ADDR-FAX-NUM | The fax number of the provider for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. | Optional | Enter the digits only (i.e., without parentheses, brackets, dashes, periods, spaces, etc.) | Not Applicable | 11/3/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV055-0001 |
| 4244 | PRV055 | ADDR-FAX-NUM | Not Applicable | NA | Value must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV055-0003 |
| 4245 | PRV055 | ADDR-FAX-NUM | Not Applicable | NA | Valid fax number including the area code. |
Not Applicable | 2/25/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV055-0004 |
| 4246 | PRV055 | ADDR-FAX-NUM | Not Applicable | NA | If unknown,leave blank or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV055-0005 |
| 4247 | PRV056 | ADDR-BORDER-STATE-IND | A code indicating that the location is outside of state boundaries for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Required | Value must be equal to a valid value | 0 No 1 Yes 8 State does not distinguish “border state providers”. |
9/23/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV056-0001 |
| 4248 | PRV056 | ADDR-BORDER-STATE-IND | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV056-0002 |
| 4249 | PRV056 | ADDR-BORDER-STATE-IND | Not Applicable | NA | Value must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV056-0003 |
| 4250 | PRV056 | ADDR-BORDER-STATE-IND | Not Applicable | NA | If unknown,leave blank or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV056-0004 |
| 4251 | PRV057 | ADDR-COUNTY | The ANSI county code for the location being captured on the PROV-LOCATION-AND-CONTACT-INFO record. |
Required | Value must be equal to a valid value. | http://www.census.gov/geo/reference/codes/countylookup.html | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV057-0001 |
| 4252 | PRV057 | ADDR-COUNTY | Not Applicable | NA | Must be populated on every record | Not Applicable | 10/10/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV057-0002 |
| 4253 | PRV057 | ADDR-COUNTY | Not Applicable | NA | Value must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV057-0003 |
| 4254 | PRV058 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV058-0001 |
| 4255 | PRV058 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV058-0002 |
| 4256 | PRV059 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | PRV059-0001 |
| 4257 | PRV060 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00004 | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV060-0001 |
| 4258 | PRV060 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV060-0002 |
| 4259 | PRV061 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV061-0001 |
| 4260 | PRV061 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV061-0002 |
| 4261 | PRV061 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV061-0003 |
| 4262 | PRV061 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV061-0004 |
| 4263 | PRV062 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Value must be an 11-digit integer with no commas. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV062-0001 |
| 4264 | PRV062 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV062-0002 |
| 4265 | PRV062 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV062-0003 |
| 4266 | PRV063 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV063-0001 |
| 4267 | PRV064 | PROV-LOCATION-ID | A code to uniquely identify the geographic locations where the provider performs services. These codes will also be reported in the PROV-LOCATION-ID field on CLAIM-HEADER-RECORD-IP, -LT, -OT, and –RX record segments | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV064-0001 |
| 4268 | PRV064 | PROV-LOCATION-ID | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV064-0002 |
| 4269 | PRV064 | PROV-LOCATION-ID | Not Applicable | NA | Each of a provider entity’s locations must have a unique PROV-LOCATION-ID | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV064-0003 |
| 4270 | PRV064 | PROV-LOCATION-ID | Not Applicable | NA | If a particular license is applicable to all locations, use the value ‘000’ value to represent ‘all’ locations. | Not Applicable | 9/23/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV064-0004 |
| 4271 | PRV065 | PROV-LICENSE-EFF-DATE | Beginning date of the time period covered by this file. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV065-0001 |
| 4272 | PRV065 | PROV-LICENSE-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV065-0002 |
| 4273 | PRV065 | PROV-LICENSE-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV065-0003 |
| 4274 | PRV065 | PROV-LICENSE-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV065-0004 |
| 4275 | PRV065 | PROV-LICENSE-EFF-DATE | Not Applicable | NA | The PROV-LICENSE-EFF-DATE must occur on or before the PROV-LICENSE-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV065-0005 |
| 4276 | PRV065 | PROV-LICENSE-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable |
| 4277 | PRV065 | PROV-LICENSE-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LICENSING-INFO record segment changes, a new record segment must be created. | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV065-0006 |
| 4278 | PRV066 | PROV-LICENSE-END-DATE | The last day of the time span during which the values in all data elements in the PROV-LICENSING-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created) | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0001 |
| 4279 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0002 |
| 4280 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable |
| 4281 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable |
| 4282 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0003 |
| 4283 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LICENSING-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0004 |
| 4284 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | The PROV-LICENSE-END-DATE must occur on or after the PROV-LICENSE-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0005 |
| 4285 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state & Prov ID, Location ID, License Type, License Issuing Entity ID | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0006 |
| 4286 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0007 |
| 4287 | PRV066 | PROV-LICENSE-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN and PROV-LOCATION-AND-CONTACT-INFO record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV066-0008 |
| 4288 | PRV067 | LICENSE-TYPE | A code to identify the kind of license or accreditation number that is captured in the LICENSE-OR-ACCREDITATION-NUMBER data element. | Conditional | Value must be equal to a valid value. | 1 State, county, or municipality professional or business license 2 DEA license 3 Professional society accreditation 4 CLIA accreditation 5 Other |
11/3/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV067-0001 |
| 4289 | PRV067 | LICENSE-TYPE | Not Applicable | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV067-0002 |
| 4290 | PRV067 | LICENSE-TYPE | Not Applicable | NA | Required whenever a Medicaid/CHIP provider is required by the state’s Medicaid/CHIP agency requires one in order to be a Medicaid/CHIP provider. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV067-0003 |
| 4291 | PRV067 | LICENSE-TYPE | Not Applicable | NA | If unknown, enter “9.”. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV067-0004 |
| 4292 | PRV068 | LICENSE-ISSUING-ENTITY-ID | A free text field to capture the identity of the entity issuing the license or accreditation. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0001 |
| 4293 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | (Enter the applicable state code, county code, municipality name, "DEA", professional society's name, or the CLIA accreditation body's name.) | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0002 |
| 4294 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | Required whenever a value is captured in the LICENSE-OR-ACCREDITATION-NUMBER data element. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0003 |
| 4295 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | If LICENSE-TYPE = 1 (State, county, or municipality professional or business license) and the license-issuing entity is a state, then enter the applicable ANSI state numeric code. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0004 |
| 4296 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | If LICENSE-TYPE = 1 (State, county, or municipality professional or business license) and the license-issuing entity is a county, then enter a 5-digit, concatenated code consisting of the ANSI state numeric code plus the ANSI county numeric code of the applicable. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0005 |
| 4297 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | If LICENSE-TYPE = 1 (State, county, or municipality professional or business license) and the license-issuing entity is a municipality, then enter a text string with the name of the municipality. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0006 |
| 4298 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | If LICENSE-TYPE = 1 (State, county, or municipality professional or business license) and the license-issuing entity is a municipality, then enter a text string with the name of the municipality. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0007 |
| 4299 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | If LICENSE-TYPE = 2 (DEA license), then enter the text string “DEA”. | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0008 |
| 4300 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | If LICENSE-TYPE = 3 (Professional society accreditation), then enter the text string identifying the professional society issuing the accreditation | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0009 |
| 4301 | PRV068 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | NA | If LICENSE-TYPE = 4 (CLIA accreditation), then enter the text string identifying the CLIA accreditation body’s name | Not Applicable | 2/25/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV068-0010 |
| 4302 | PRV069 | LICENSE-OR-ACCREDITATION-NUMBER | A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the LICENSE-ISSUING-ENTITY-ID data element. | Conditional | Required whenever the LICENSE-TYPE and LICENSE-ISSUING-ENTITY-ID data elements are populated | Not Applicable | 11/3/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV069-0001 |
| 4303 | PRV069 | LICENSE-OR-ACCREDITATION-NUMBER | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV069-0002 |
| 4304 | PRV070 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV070-0001 |
| 4305 | PRV070 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV070-0002 |
| 4306 | PRV071 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-LICENSING-INFO-PRV00004 | PRV071-0001 |
| 4307 | PRV072 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00005 | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV072-0001 |
| 4308 | PRV072 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV072-0002 |
| 4309 | PRV073 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV073-0001 |
| 4310 | PRV073 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV073-0002 |
| 4311 | PRV073 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV073-0003 |
| 4312 | PRV073 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV073-0004 |
| 4313 | PRV074 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Value must be an 11-digit integer with no commas. | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV074-0001 |
| 4314 | PRV074 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV074-0002 |
| 4315 | PRV074 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV074-0003 |
| 4316 | PRV075 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV075-0001 |
| 4317 | PRV076 | PROV-LOCATION-ID | A code to uniquely identify the geographic locations where the provider performs services. These codes will also be reported in the PROV-LOCATION-ID field on CLAIM-HEADER-RECORD-IP, -LT, -OT, and –RX record segments | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV076-0001 |
| 4318 | PRV076 | PROV-LOCATION-ID | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV076-0002 |
| 4319 | PRV076 | PROV-LOCATION-ID | Not Applicable | NA | Each of a provider entity’s locations must have a unique PROV-LOCATION-ID | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV076-0003 |
| 4320 | PRV076 | PROV-LOCATION-ID | Not Applicable | NA | If a particular license is applicable to all locations, use the value ‘000’ value to represent ‘all’ locations. | Not Applicable | 9/23/2015 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV076-0004 |
| 4321 | PRV077 | PROV-IDENTIFIER-TYPE | A code to identify the kind of provider identifier that is captured in the PROV-IDENTIFIER data element. | Required | Value must be equal to a valid value. | 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 |
8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV077-0001 |
| 4322 | PRV077 | PROV-IDENTIFIER-TYPE | Not Applicable | NA | Required whenever a value is captured in the PROV-IDENTIFIER data element. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV077-0002 |
| 4323 | PRV077 | PROV-IDENTIFIER-TYPE | Not Applicable | NA | The state should provide the identifiers associated with the provider for identifier types 1 through 7 whenever it is applicable to the provider. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV077-0003 |
| 4324 | PRV077 | PROV-IDENTIFIER-TYPE | Not Applicable | NA | The state should submit updates to T-MSIS whenever an identifier is retired or issued. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV077-0004 |
| 4325 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | A free text field to capture the identity of the entity that issued the provider identifier in the PROV-IDENTIFIER data element. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0001 |
| 4326 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | Required whenever a value is captured in the PROV-IDENTIFIER data element. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0002 |
| 4327 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | If PROV-IDENTIFIER-TYPE = 1 (State-specific Medicaid Provider ID), then enter the applicable ANSI state numeric code. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0003 |
| 4328 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | If PROV-IDENTIFIER-TYPE = 2 (NPI), then enter “NPI.” | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0004 |
| 4329 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | If PROV-IDENTIFIER-TYPE = 3 (Medicare). Then enter “CMS” | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0005 |
| 4330 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | If PROV-IDENTIFIER-TYPE = 4 (NCPDP ID) then enter “NCPDP” | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0006 |
| 4331 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | If PROV-IDENTIFIER-TYPE = 5 (Federal Tax ID), then enter the text string “IRS”. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0007 |
| 4332 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | If PROV-IDENTIFIER-TYPE = 6 (State Tax ID), then text string of the name of the state’s taxation division.. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0008 |
| 4333 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | 'If PROV-IDENTIFIER-TYPE = 7 (SSN), then enter the text string “SSA”. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable |
| 4334 | PRV078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | NA | If PROV-IDENTIFIER-TYPE = 8 (Other), then enter the name of the entity. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV078-0009 |
| 4335 | PRV079 | PROV-IDENTIFIER-EFF-DATE | The first day of the time span during which the values in all data elements in the PROV-IDENTIFIERS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV079-0001 |
| 4336 | PRV079 | PROV-IDENTIFIER-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV079-0002 |
| 4337 | PRV079 | PROV-IDENTIFIER-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV079-0003 |
| 4338 | PRV079 | PROV-IDENTIFIER-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV079-0004 |
| 4339 | PRV079 | PROV-IDENTIFIER-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable |
| 4340 | PRV079 | PROV-IDENTIFIER-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LICENSING-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV079-0005 |
| 4341 | PRV079 | PROV-IDENTIFIER-EFF-DATE | Not Applicable | NA | The PROV-IDENTIFIER-EFF-DATE must occur on or before the PROV-IDENTIFIER-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV079-0006 |
| 4342 | PRV080 | PROV-IDENTIFIER-END-DATE | The last day of the time span during which the values in all data elements in the PROV-IDENTIFIERS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0001 |
| 4343 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0002 |
| 4344 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0003 |
| 4345 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0004 |
| 4346 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable |
| 4347 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable |
| 4348 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LICENSING-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0005 |
| 4349 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | The PROV-IDENTIFIER-END-DATE must occur on or after the PROV-IDENTIFIER-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0006 |
| 4350 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state & Prov ID, Location ID, Prov Identifier Type, Prov Identifier | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0007 |
| 4351 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0008 |
| 4352 | PRV080 | PROV-IDENTIFIER-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN and PROV-LOCATION-AND-CONTACT-INFO record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV080-0009 |
| 4353 | PRV081 | PROV-IDENTIFIER | A data element to capture the various ways used to distinguish providers from one another on claims and other interactions between providers and other entities. The specific type of identifier is shown in the corresponding value in the IDENTIFIER-TYPE data element. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 9/23/2015 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV081-0001 |
| 4354 | PRV081 | PROV-IDENTIFIER | Not Applicable | NA | The value in the PROV-IDENTIFIER data element should be a valid value in the enumeration entity’s identification schema. | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV081-0002 |
| 4355 | PRV081 | PROV-IDENTIFIER | Not Applicable | NA | The state should submit updates to T-MSIS whenever an identifier is retired or issued | Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV081-0003 |
| 4356 | PRV081 | PROV-IDENTIFIER | Not Applicable | NA | The state should provide the identifiers associated with the provider for identifier types 1 through 7 whenever it is applicable to the provider Conditions When CMS Expects a PROV-IDENTIFIER Value: • State-specific Medicaid Provider ID (the state should supply this identifier for every provider, since it is the state itself that is using the identifier in its MMIS.) • NPI (the state should supply this identifier for every provider who is issued an NPI). • Medicare ID (the state should supply this identifier for every provider who is issued a Medicare ID) • NCPDP ID (The state should supply this for every pharmacy.) • Federal Tax ID (the state should supply this identifier for every provider who uses a federal TIN as its identifier with the IRS.) • State Tax ID (the state should supply this identifier for every provider who uses a state TIN as its identifier with the state tax authority.) • SSN (the state should supply this identifier for every provider who uses a social security number as his/her identifier with the IRS and/or the state tax authority.) • Other (whenever the state uses an identifier type other than those listed above that it believes would be useful to analysts using the state’s Medicaid/CHIP data.) |
Not Applicable | 2/25/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV081-0004 |
| 4357 | PRV081 | PROV-IDENTIFIER | Not Applicable | NA | The PROV-IDENTIFIER data element must be populated whenever the PROV-IDENTIFIER-TYPE is populated | Not Applicable | 4/30/2013 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV081-0005 |
| 4358 | PRV081 | PROV-IDENTIFIER | Not Applicable | NA | One record should be reported on the PROV-IDENTIFIERS-PRV00005 file segment with the SUBMITTING-STATE-PROV-ID value reported in the PROV-IDENTIFIER field and a PROV-IDENTIFIER-TYPE="1". | Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV081-0006 |
| 4359 | PRV082 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV082-0001 |
| 4360 | PRV082 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV082-0002 |
| 4361 | PRV083 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-IDENTIFIERS-PRV00005 | PRV083-0001 |
| 4362 | PRV084 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00006 | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV084-0001 |
| 4363 | PRV084 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV084-0002 |
| 4364 | PRV085 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV085-0001 |
| 4365 | PRV085 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV085-0002 |
| 4366 | PRV085 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV085-0003 |
| 4367 | PRV085 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV085-0004 |
| 4368 | PRV086 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Value must be an 11-digit integer with no commas. | Not Applicable | 4/30/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV086-0001 |
| 4369 | PRV086 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV086-0002 |
| 4370 | PRV086 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV086-0003 |
| 4371 | PRV087 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV087-0001 |
| 4372 | PRV088 | PROV-CLASSIFICATION-TYPE | A code to identify the schema used in the PROV-CLASSIFICATION-CODE field to categorize providers. | Required | Value must be equal to a valid value. | 1 Taxonomy code 2 Provider specialty code 3 Provider type code 4 Authorized category of service code |
8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV088-0001 |
| 4373 | PRV088 | PROV-CLASSIFICATION-TYPE | Not Applicable | NA | Required on every PROV-TAXONOMY-CLASSIFICATION record | Not Applicable | 2/25/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV088-0002 |
| 4374 | PRV088 | PROV-CLASSIFICATION-TYPE | Not Applicable | NA | Provide a value for all 4 provider classification types. Each provider should have a separate PROV-TAXONOMY-CLASSIFICATION-PRV00006 record segment for each of the values – Taxonomy Code, Provider Specialty Code, Provider Type Code, & Authorized Category of Service Code – unless one of the values is not applicable to that provider. | Not Applicable | 10/10/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV088-0003 |
| 4375 | PRV088 | PROV-CLASSIFICATION-TYPE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting PROV‐CLASSIFICATION‐TYPE and PROV‐CLASSIFICATION‐CODE in the T‐MSIS Provider File" | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV088-0004 |
| 4376 | PRV088 | PROV-CLASSIFICATION-TYPE | Not Applicable | NA | A provider may be reported with multiple active record segments with the same PROV-CLASSIFICATION-TYPE if different PROV-CLASSIFICATION-CODE values apply | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV088-0005 |
| 4377 | PRV089 | PROV-CLASSIFICATION-CODE | The code values from the categorization schema identified in the PROV-CLASSIFICATION-TYPE data element. Valid value lists for each PROV-CLASSIFICATION-TYPE code are listed. Note: States should apply these classification schemas consistently across all providers. |
Required | Dependent value must be equal to a valid value. | See Appendix A for listing of valid values. | 9/23/2015 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV089-0001 |
| 4378 | PRV089 | PROV-CLASSIFICATION-CODE | Not Applicable | NA | Required on every PROV-TAXONOMY-CLASSIFICATION segment. | Not Applicable | 10/10/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV089-0002 |
| 4379 | PRV089 | PROV-CLASSIFICATION-CODE | Not Applicable | NA | The value in the PROV-CLASSIFICATION-CODE data element must correspond to the valid values set identified in the PROV-CLASSIFICATION-TYPE data element. | Not Applicable | 2/25/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV089-0003 |
| 4380 | PRV089 | PROV-CLASSIFICATION-CODE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting PROV‐CLASSIFICATION‐TYPE and PROV‐CLASSIFICATION‐CODE in the T‐MSIS Provider File" | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV089-0004 |
| 4381 | PRV090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | The first day of the time span during which the values in all data elements in the PROV-TAXONOMY-CLASSIFICATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV090-0001 |
| 4382 | PRV090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV090-0002 |
| 4383 | PRV090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV090-0003 |
| 4384 | PRV090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV090-0004 |
| 4385 | PRV090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable |
| 4386 | PRV090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LICENSING-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV090-0005 |
| 4387 | PRV090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Not Applicable | NA | The PROV-TAXONOMY-CLASSIFICATION-EFF-DATE must occur on or before the PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV090-0006 |
| 4388 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | The last day of the time span during which the values in all data elements in the PROV-TAXONOMY-CLASSIFICATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0001 |
| 4389 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0002 |
| 4390 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0003 |
| 4391 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0004 |
| 4392 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable |
| 4393 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable |
| 4394 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-LICENSING-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0005 |
| 4395 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | The PROV-TAXONOMY-CLASSIFICATION-END-DATE must occur on or after the PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0006 |
| 4396 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state & Prov ID, Classification Type, Classification Code | Not Applicable | 4/30/2013 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0007 |
| 4397 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0008 |
| 4398 | PRV091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV091-0009 |
| 4399 | PRV092 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV092-0001 |
| 4400 | PRV092 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV092-0002 |
| 4401 | PRV093 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | PRV093-0001 |
| 4402 | PRV094 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00007 | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV094-0001 |
| 4403 | PRV094 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV094-0002 |
| 4404 | PRV095 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV095-0001 |
| 4405 | PRV095 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV095-0002 |
| 4406 | PRV095 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV095-0003 |
| 4407 | PRV095 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV095-0004 |
| 4408 | PRV096 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Value must be an 11-digit integer with no commas. | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV096-0001 |
| 4409 | PRV096 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV096-0002 |
| 4410 | PRV096 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV096-0003 |
| 4411 | PRV097 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Required | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV097-0001 |
| 4412 | PRV098 | PROV-MEDICAID-EFF-DATE | The first day of the time span during which the values in all data elements on a PROV-MEDICAID record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV098-0001 |
| 4413 | PRV098 | PROV-MEDICAID-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable |
| 4414 | PRV098 | PROV-MEDICAID-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV098-0002 |
| 4415 | PRV098 | PROV-MEDICAID-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV098-0003 |
| 4416 | PRV098 | PROV-MEDICAID-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-MEDICAID-ENROLLMENT record segment changes, a new record segment must be created. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable |
| 4417 | PRV098 | PROV-MEDICAID-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable |
| 4418 | PRV098 | PROV-MEDICAID-EFF-DATE | Not Applicable | NA | The PROV-MEDICAID-EFF-DATE must occur on or before the PROV-MEDICAID-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV098-0005 |
| 4419 | PRV099 | PROV-MEDICAID-END-DATE | The last day of the time span during which the values in all data elements on a PROV-MEDICAID record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV099-0001 |
| 4420 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV099-0002 |
| 4421 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV099-0003 |
| 4422 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable |
| 4423 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable |
| 4424 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | The PROV-MEDICAID-END-DATE must occur on or after the PROV-MEDICAID-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV099-0005 |
| 4425 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state & Prov ID, Enrollment Status Code | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV099-0006 |
| 4426 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV099-0007 |
| 4427 | PRV099 | PROV-MEDICAID-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV099-0008 |
| 4428 | PRV100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | A code representing the provider’s Medicaid and/or CHIP enrollment status for the time span specified by the PROV-MEDICAID-EFF-DATE and PROV-MEDICAID-END-DATE data elements. Note: The STATE-PLAN-ENROLLMENT data element identifies whether the provider is enrolled in Medicaid, CHIP, or both. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV100-0001 |
| 4429 | PRV100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV100-0002 |
| 4430 | PRV100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Not Applicable | NA | A health home provider must be active to be an eligible individual's primary care manager for the health home in which the individual is enrolled. | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV100-0003 |
| 4431 | PRV100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Not Applicable | NA | A lockin provider must be active to be a provider furnishing locked-in healthcare services to an individual. | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV100-0004 |
| 4432 | PRV100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Not Applicable | NA | A LTSS provider must be active to be a long term care facility furnishing healthcare services to an individual. | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV100-0005 |
| 4433 | PRV101 | STATE-PLAN-ENROLLMENT | The state plan with which a provider has an affiliation and is able to provide services to the state’s fee for service enrollees. | Required | Value must be equal to a valid value. | 1 Medicaid 2 CHIP 3 Both Medicaid and CHIP 4 Not state plan affiliated |
10/10/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV101-0001 |
| 4434 | PRV102 | PROV-ENROLLMENT-METHOD | Process by which a provider was enrolled in Medicaid or CHIP. | Required | Value must be equal to a valid value. | 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 |
10/10/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV102-0001 |
| 4435 | PRV103 | APPL-DATE | The date on which the provider applied for enrollment into the State’s Medicaid and/or CHIP program. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV103-0001 |
| 4436 | PRV103 | APPL-DATE | Not Applicable | NA | The date must be a valid date. | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV103-0002 |
| 4437 | PRV103 | APPL-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV103-0003 |
| 4438 | PRV103 | APPL-DATE | Not Applicable | NA | APPL-DATE should not be less than PROV-MEDICAID-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV103-0005 |
| 4439 | PRV104 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV104-0001 |
| 4440 | PRV104 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV104-0002 |
| 4441 | PRV105 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | PRV105-0001 |
| 4442 | PRV106 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00008 | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV106-0001 |
| 4443 | PRV106 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV106-0002 |
| 4444 | PRV107 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV107-0001 |
| 4445 | PRV107 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV107-0002 |
| 4446 | PRV107 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV107-0003 |
| 4447 | PRV107 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV107-0004 |
| 4448 | PRV108 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV108-0001 |
| 4449 | PRV108 | RECORD-NUMBER | Not Applicable | NA | Value must be an 11-digit integer with no commas. | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV108-0002 |
| 4450 | PRV108 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV108-0003 |
| 4451 | PRV109 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV109-0001 |
| 4452 | PRV109 | SUBMITTING-STATE-PROV-ID | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting T-MSIS Data Pursuant to SHO #16-002 (Federal Funding for Services “Received Through” an IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives)" | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable |
| 4453 | PRV110 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | The unique, state-assigned identification number for the group or subpart with which the individual or subpart is associated. (The submitting state's unique identifier for the group. (Note: The group will also in the provider data set as a provider (i.e., the group-as-a-provider).) | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV110-0001 |
| 4454 | PRV110 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Not Applicable | NA | Right-fill with spaces if the value is not 12 bytes long. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV110-0002 |
| 4455 | PRV110 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting T-MSIS Data Pursuant to SHO #16-002 (Federal Funding for Services “Received Through” an IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives)" | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable |
| 4456 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | The first day of the time span during which the values in all data elements in the PROV-AFFILIATED-GROUPS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV111-0001 |
| 4457 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV111-0002 |
| 4458 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV111-0003 |
| 4459 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV111-0004 |
| 4460 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable |
| 4461 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-AFFILIATED-GROUPS record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV111-0005 |
| 4462 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | NA | The PROV-AFFILIATED-GROUP-EFF-DATE must occur on or before the PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV111-0006 |
| 4463 | PRV111 | PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting T-MSIS Data Pursuant to SHO #16-002 (Federal Funding for Services “Received Through” an IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives)" | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable |
| 4464 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | The last day of the time span during which the values in all data elements in the PROV-AFFILIATED-GROUPS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0001 |
| 4465 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0002 |
| 4466 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0003 |
| 4467 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0004 |
| 4468 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable |
| 4469 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable |
| 4470 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-AFFILIATED-GROUPS record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0005 |
| 4471 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | The PROV-AFFILIATED-GROUP-END-DATE must occur on or after the PROV-AFFILIATED-GROUP-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0006 |
| 4472 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same state & Prov ID, Prov ID of Affiliated Entity | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0007 |
| 4473 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0008 |
| 4474 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV112-0009 |
| 4475 | PRV112 | PROV-AFFILIATED-GROUP-END-DATE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Reporting T-MSIS Data Pursuant to SHO #16-002 (Federal Funding for Services “Received Through” an IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives)" | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable |
| 4476 | PRV113 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV113-0001 |
| 4477 | PRV113 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV113-0002 |
| 4478 | PRV114 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | PRV114-0001 |
| 4479 | PRV115 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00009 | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV115-0001 |
| 4480 | PRV115 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV115-0002 |
| 4481 | PRV116 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV116-0001 |
| 4482 | PRV116 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV116-0002 |
| 4483 | PRV116 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV116-0003 |
| 4484 | PRV116 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV116-0004 |
| 4485 | PRV117 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Value must be an 11-digit integer with no commas. | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV117-0001 |
| 4486 | PRV117 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV117-0002 |
| 4487 | PRV117 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV117-0003 |
| 4488 | PRV118 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV118-0001 |
| 4489 | PRV119 | AFFILIATED-PROGRAM-TYPE | A code to identify the category of program that the provider is affiliated. | Conditional | Value must be equal to a valid value. | 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. (Valid Value not currently active) 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 |
8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV119-0001 |
| 4490 | PRV119 | AFFILIATED-PROGRAM-TYPE | Not Applicable | NA | Required on every PROV-AFFILIATED-PROGRAMS record. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV119-0002 |
| 4491 | PRV120 | AFFILIATED-PROGRAM-ID | A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. | Conditional | If AFFILIATED-PROGRAM-TYPE <> spaces, then AFFILIATED-PROGRAM-ID must be <> spaces. | Not Applicable | 11/3/2015 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0001 |
| 4492 | PRV120 | AFFILIATED-PROGRAM-ID | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0002 |
| 4493 | PRV120 | AFFILIATED-PROGRAM-ID | Not Applicable | NA | If AFFILIATED-PROGRAM-TYPE = 2 (Health Plan State-assigned health plan ID), then the value in AFFILIATED-PROGRAM-ID is the state-assigned plan ID of the health plan in which a provider is enrolled to provide services. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0004 |
| 4494 | PRV120 | AFFILIATED-PROGRAM-ID | Not Applicable | NA | If AFFILIATED-PROGRAM-TYPE = 3 (Waiver), then the value in AFFILIATED-PROGRAM-ID states should report the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0005 |
| 4495 | PRV120 | AFFILIATED-PROGRAM-ID | Not Applicable | NA | If AFFILIATED-PROGRAM-TYPE = 4 (Health Home Entity), then the value in AFFILIATED-PROGRAM-ID is the name of a health home in which a provider is participating. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0006 |
| 4496 | PRV120 | AFFILIATED-PROGRAM-ID | Not Applicable | NA | If AFFILIATED-PROGRAM-TYPE = 5 (Other), then the value in AFFILIATED-PROGRAM-ID is an identifier for something other than a health plan, waiver, or health home entity. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0007 |
| 4497 | PRV120 | AFFILIATED-PROGRAM-ID | Not Applicable | NA | If the value entered into the AFFILIATED-PROGRAM-ID is less than 50 bytes long, right-pad with spaces. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0008 |
| 4498 | PRV120 | AFFILIATED-PROGRAM-ID | Not Applicable | NA | If the value entered into the AFFILIATED-PROGRAM-ID is more than 50 bytes long, truncate the bytes. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV120-0009 |
| 4499 | PRV121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | The first day of the time span during which the values in all data elements in the PROV-AFFILIATED-PROGRAMS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV121-0001 |
| 4500 | PRV121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV121-0002 |
| 4501 | PRV121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV121-0003 |
| 4502 | PRV121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV121-0004 |
| 4503 | PRV121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable |
| 4504 | PRV121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-AFFILIATED-PROGRAMS record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV121-0005 |
| 4505 | PRV121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Not Applicable | NA | The PROV-AFFILIATED-PROGRAM-EFF-DATE must occur on or before the PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV121-0006 |
| 4506 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | The last day of the time span during which the values in all data elements in the PROV-AFFILIATED-PROGRAMS record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0001 |
| 4507 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0002 |
| 4508 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0003 |
| 4509 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0004 |
| 4510 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable |
| 4511 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable |
| 4512 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-AFFILIATED-PROGRAMS record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0005 |
| 4513 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | The PROV-AFFILIATED-PROGRAM-END-DATE must occur on or after the PROV-AFFILIATED-PROGRAM-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0006 |
| 4514 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same state & Prov ID, Affiliated Program Type, Affiliated Program ID | Not Applicable | 4/30/2013 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0007 |
| 4515 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0008 |
| 4516 | PRV122 | PROV-AFFILIATED-PROGRAM-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV122-0009 |
| 4517 | PRV123 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV123-0001 |
| 4518 | PRV123 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV123-0002 |
| 4519 | PRV124 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | PRV124-0001 |
| 4520 | PRV125 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | PRV00010 | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV125-0001 |
| 4521 | PRV125 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV125-0002 |
| 4522 | PRV126 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV126-0001 |
| 4523 | PRV126 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV126-0002 |
| 4524 | PRV126 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV126-0003 |
| 4525 | PRV126 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV126-0004 |
| 4526 | PRV127 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Value must be an 11-digit integer with no commas. | Not Applicable | 4/30/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV127-0001 |
| 4527 | PRV127 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 4/30/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV127-0002 |
| 4528 | PRV127 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 4/30/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV127-0003 |
| 4529 | PRV128 | SUBMITTING-STATE-PROV-ID | The state-assigned unique identifier for the provider entity. Note that all individuals, practice groups, facilities, and other entities that provide Medicaid/CHIP goods or services to the state’s Medicaid/CHIP enrollees should be reflected in the T-MSIS provider data set. | Conditional | Must be populated on every record | Not Applicable | 11/3/2015 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV128-0001 |
| 4530 | PRV129 | PROV-LOCATION-ID | A code to uniquely identify the geographic locations where the provider performs services. These codes will also be reported in the PROV-LOCATION-ID field on CLAIM-HEADER-RECORD-IP, -LT, -OT, and –RX record segments | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV129-0001 |
| 4531 | PRV129 | PROV-LOCATION-ID | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV129-0002 |
| 4532 | PRV129 | PROV-LOCATION-ID | Not Applicable | NA | Each of a provider entity’s locations must have a unique PROV-LOCATION-ID | Not Applicable | 2/25/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV129-0003 |
| 4533 | PRV129 | PROV-LOCATION-ID | Not Applicable | NA | If a particular license is applicable to all locations, use the value ‘000’ value to represent ‘all’ locations. | Not Applicable | 9/23/2015 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV129-0004 |
| 4534 | PRV130 | BED-TYPE-EFF-DATE | The first day of the time span during which the values in all data elements in the PROV-BED-TYPE-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV130-0001 |
| 4535 | PRV130 | BED-TYPE-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV130-0002 |
| 4536 | PRV130 | BED-TYPE-EFF-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV130-0003 |
| 4537 | PRV130 | BED-TYPE-EFF-DATE | Not Applicable | NA | The BED-TYPE-EFF-DATE must occur on or before the BED-TYPE-END-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV130-0004 |
| 4538 | PRV130 | BED-TYPE-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV130-0005 |
| 4539 | PRV130 | BED-TYPE-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable |
| 4540 | PRV130 | BED-TYPE-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-BED-TYPE-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV130-0006 |
| 4541 | PRV130 | BED-TYPE-EFF-DATE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T‐MSIS Provider File" | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV130-0007 |
| 4542 | PRV131 | BED-TYPE-END-DATE | The last day of the time span during which the values in all data elements in the PROV-BED-TYPE-INFO record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0001 |
| 4543 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0002 |
| 4544 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | Must be populated on every record | Not Applicable | 4/30/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0003 |
| 4545 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | The BED-TYPE-END-DATE must occur on or after the BED-TYPE-EFF-DATE | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0004 |
| 4546 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable |
| 4547 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable |
| 4548 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the PROV-BED-TYPE-INFO record segment changes, a new record segment must be created. | Not Applicable | 10/10/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0005 |
| 4549 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same Submitting state & Prov ID, Location ID, Bed Type Code | Not Applicable | 10/10/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0006 |
| 4550 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0007 |
| 4551 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | Active PROV-ATTRIBUTES-MAIN and PROV-LOCATION-AND-CONTACT-INFO record should exist in T-MSIS database or contained in the current submission | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0008 |
| 4552 | PRV131 | BED-TYPE-END-DATE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T‐MSIS Provider File" | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV131-0009 |
| 4553 | PRV134 | BED-TYPE-CODE | A code to classify beds available at a facility. | Conditional | Value must be equal to a valid value. | 1 Intermediate Care Facility for the Intellectually Disabled 2 Inpatient 3 Nursing Facility 4 Title 18 Skilled Nursing Facility (T18 SNF) |
8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV134-0001 |
| 4554 | PRV134 | BED-TYPE-CODE | Not Applicable | NA | Must be populated on every record | Not Applicable | 2/25/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV134-0002 |
| 4555 | PRV134 | BED-TYPE-CODE | Not Applicable | NA | Report all that bed types that apply. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV134-0003 |
| 4556 | PRV134 | BED-TYPE-CODE | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T‐MSIS Provider File" | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV134-0004 |
| 4557 | PRV135 | BED-COUNT | A count of the number of beds available at the facility for the category of bed identified in the BED-TYPE-CODE data element. | Conditional | Value must be numeric | Not Applicable | 11/3/2015 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV135-0001 |
| 4558 | PRV135 | BED-COUNT | Not Applicable | NA | Must be less than zero | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV135-0002 |
| 4559 | PRV135 | BED-COUNT | Not Applicable | NA | Left-fill with zeros if value is less than 5 bytes long | Not Applicable | 2/25/2013 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV135-0003 |
| 4560 | PRV135 | BED-COUNT | Not Applicable | NA | Beds should not be counted twice under different bed types. | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV135-0004 |
| 4561 | PRV135 | BED-COUNT | Not Applicable | NA | See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T‐MSIS Provider File" | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV135-0005 |
| 4562 | PRV136 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV136-0001 |
| 4563 | PRV136 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV136-0002 |
| 4564 | PRV137 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | PRV137-0001 |
| 4565 | PRV138 | SEQUENCE-NUMBER | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' record files. | Not Applicable | 8/7/2017 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV138-0001 |
| 4566 | PRV138 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | PRV138-0002 |
| 4567 | TPL001 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | TPL00001 | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL001-0001 |
| 4568 | TPL001 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL001-0003 |
| 4569 | TPL002 | DATA-DICTIONARY-VERSION | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. | Required | Use the version number specified on the Cover Sheet of the data dictionary | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL002-0001 |
| 4570 | TPL003 | SUBMISSION-TRANSACTION-TYPE | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Required | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 4/30/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL003-0001 |
| 4571 | TPL003 | SUBMISSION-TRANSACTION-TYPE | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL003-0002 |
| 4572 | TPL004 | FILE-ENCODING-SPECIFICATION | A data element to denote whether the file is in fixed length line format or delimited format. | Required | Value must be equal to a valid value. | FLF - The file follows a fixed length format. PSV - The file follows a pipe-delimited format. |
8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL004-0001 |
| 4573 | TPL005 | DATA-MAPPING-DOCUMENT-VERSION | A data element to identify the version of the T-MSIS data mapping document used to build the file. | Required | Use the version number specified on the title page of the data mapping document | Not Applicable | 2/25/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL005-0001 |
| 4574 | TPL006 | FILE-NAME | The name identifying the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party Liability, Provider, Managed Care Plan Information, IP claims, LT claims, Rx claims, or OT claims). | Required | Required on every file header record | Not Applicable | 2/25/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL006-0001 |
| 4575 | TPL006 | FILE-NAME | Not Applicable | NA | Value must be equal to a valid value. | TPL-FILE - Third-party Liability file | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL006-0002 |
| 4576 | TPL006 | FILE-NAME | Not Applicable | NA | Right-fill with spaces if name is less than 8 bytes long | Not Applicable | 4/30/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL006-0003 |
| 4577 | TPL007 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL007-0002 |
| 4578 | TPL007 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL007-0001 |
| 4579 | TPL007 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4580 | TPL007 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4581 | TPL008 | DATE-FILE-CREATED | The date on which the file was created. | Required | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 2/25/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL008-0001 |
| 4582 | TPL008 | DATE-FILE-CREATED | Not Applicable | NA | Value must be a valid date | Not Applicable | 4/30/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL008-0002 |
| 4583 | TPL008 | DATE-FILE-CREATED | Not Applicable | NA | Date must be equal to or later than the date entered in the END-OF-TIME-PERIOD field. | Not Applicable | 2/25/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL008-0003 |
| 4584 | TPL008 | DATE-FILE-CREATED | Not Applicable | NA | Required on every file header record | Not Applicable | 4/30/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL008-0004 |
| 4585 | TPL009 | START-OF-TIME-PERIOD | Beginning date of the time period covered by this file. | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL009-0001 |
| 4586 | TPL009 | START-OF-TIME-PERIOD | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4587 | TPL009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL009-0002 |
| 4588 | TPL009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur before END-OF-TIME-PERIOD | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL009-0004 |
| 4589 | TPL009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or less than the date in the DATE-FILE-CREATED field. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4590 | TPL009 | START-OF-TIME-PERIOD | Not Applicable | NA | Value must occur on or before the current date. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4591 | TPL010 | END-OF-TIME-PERIOD | Last date of the reporting period covered by the file to which this Header Record is attached. | Required | Date format is CCYYMMDD (National Data Standard) | Not Applicable | 4/30/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL010-0001 |
| 4592 | TPL010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL010-0002 |
| 4593 | TPL010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value for the Date in the End of Time Period (last 2 bytes of the value) must equal "30" in April, June, September, or November; "31" in January, March, May, July, August, October, or December, and "28" or "29" in February. | Not Applicable | 10/10/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL010-0003 |
| 4594 | TPL010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal or less than the DATE-FILE-CREATED | Not Applicable | 4/30/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL010-0004 |
| 4595 | TPL010 | END-OF-TIME-PERIOD | Not Applicable | NA | Value must be equal to or greater than START-OF-TIME-PERIOD. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4596 | TPL010 | END-OF-TIME-PERIOD | Not Applicable | NA | Date must be less than current date | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL010-0005 |
| 4597 | TPL011 | FILE-STATUS-INDICATOR | A code to indicate whether the records in the file are test or production records. | Required | Value must be equal to a valid value. | P Production File T Test File |
8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL011-0001 |
| 4598 | TPL011 | FILE-STATUS-INDICATOR | Not Applicable | NA | Must be populated on every record | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4599 | TPL011 | FILE-STATUS-INDICATOR | Not Applicable | NA | The dataset name and the value in this field must be consistent (i.e., the production dataset name cannot have a FILE-STATUS-INDICATOR = 'T' | Not Applicable | 4/30/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL011-0002 |
| 4600 | TPL012 | SSN-INDICATOR | Indicates whether the state uses the eligible person's social security number (SSN) instead of an MSIS identification number as the unique, unchanging eligible person identifier. | Required | Value must be equal to a valid value. | 0 State does not use SSN as MSIS-IDENTIFICATION-NUMBER 1 State uses SSN as MSIS-IDENTIFICATION-NUMBER |
8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL012-0001 |
| 4601 | TPL012 | SSN-INDICATOR | Not Applicable | NA | A state's SSN/Non-SSN designation on the eligibility file should match on the TPL file. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable |
| 4602 | TPL012 | SSN-INDICATOR | Not Applicable | NA | For non-SSN states, the SSN-INDICATOR in the Header record must be set to 0 and the MSIS identification number must be reported in the MSIS-IDENTIFICATION-NUMBER field. If the MSIS-IDENTIFICATION-NUMBER is not known then this field should be 9-filled, left blank or space-filled. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL012-0002 |
| 4603 | TPL013 | TOT-REC-CNT | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Required | Value must be an integer with no commas. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL013-0001 |
| 4604 | TPL013 | TOT-REC-CNT | Not Applicable | NA | Value must equal the sum of all records excluding the header record. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL013-0002 |
| 4605 | TPL014 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL014-0001 |
| 4606 | TPL014 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL014-0002 |
| 4607 | TPL015 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL015-0001 |
| 4608 | TPL016 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | TPL00002 | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL016-0001 |
| 4609 | TPL016 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL016-0003 |
| 4610 | TPL017 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL017-0002 |
| 4611 | TPL017 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable |
| 4612 | TPL017 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL017-0001 |
| 4613 | TPL017 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL017-0003 |
| 4614 | TPL018 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL018-0001 |
| 4615 | TPL018 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL018-0002 |
| 4616 | TPL018 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL018-0003 |
| 4617 | TPL019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL019-0005 |
| 4618 | TPL019 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | For non-SSN states, this field must contain an identification number assigned by the state. The format of the State ID numbers must be supplied to CMS. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL019-0002 |
| 4619 | TPL019 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain temporary MSIS identification number. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS identification number for at least one monthly submission of the TPL File so that T-MSIS can associate the temporary MSIS-IDENTIFICATION-NUM on the TPL file with the temporary MSIS-IDENTIFICATION-NUM and SSN on the Eligibility file. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL019-0003 |
| 4620 | TPL020 | TPL-HEALTH-INSURANCE-COVERAGE-IND | A flag to indicate that the Medicaid/CHIP eligible person has some form of third party insurance coverage. | Conditional | Value must be equal to a valid value. | 0 Medicaid/CHIP eligible individual has no TPL insurance coverage 1 Medicaid/CHIP eligible individual does have TPL insurance coverage |
8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL020-0001 |
| 4621 | TPL020 | TPL-HEALTH-INSURANCE-COVERAGE-IND | Not Applicable | NA | If TPL-HEALTH-INSURANCE-COVERAGE-IND equals “1,” then there must be one or more instances where the eligible person has some form of third party insurance coverage. The records for this coverage can exist either in the T-MSIS database or be on one or more TPL-MEDICAID-ELIGIBLE-INSURANCE-COVERAGE-INFO record segments in the current TPL file submission. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL020-0002 |
| 4622 | TPL021 | TPL-OTHER-COVERAGE-IND | A flag to indicate that the Medicaid/CHIP eligible person has some other form of third party funding besides insurance coverage. | Conditional | Value must be equal to a valid value. | 0 Medicaid/CHIP eligible individual has no other TPL funding available 1 Medicaid/CHIP eligible individual does have other TPL funding available |
8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL021-0001 |
| 4623 | TPL022 | ELIGIBLE-FIRST-NAME | The first name of the individual to whom the services were provided. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL022-0001 |
| 4624 | TPL023 | ELIGIBLE-MIDDLE-INIT | The middle initial of the individual to whom the services were provided. | Conditional | Leave blank if not available | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable |
| 4625 | TPL023 | ELIGIBLE-MIDDLE-INIT | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL023-0001 |
| 4626 | TPL024 | ELIGIBLE-LAST-NAME | The last name of the individual to whom the services were provided. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL024-0001 |
| 4627 | TPL025 | ELIG-PRSN-MAIN-EFF-DATE | The first day of the time span during which the values in all data elements in the ELIG-PRSN-MAIN-EFF-DATE record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL025-0001 |
| 4628 | TPL025 | ELIG-PRSN-MAIN-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL025-0002 |
| 4629 | TPL025 | ELIG-PRSN-MAIN-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL025-0003 |
| 4630 | TPL025 | ELIG-PRSN-MAIN-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable |
| 4631 | TPL025 | ELIG-PRSN-MAIN-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-MAIN record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL025-0004 |
| 4632 | TPL025 | ELIG-PRSN-MAIN-EFF-DATE | Not Applicable | NA | The ELIG-PRSN-MAIN-EFF-DATE must occur on or before the ELIG-PRSN-MAIN-END-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL025-0005 |
| 4633 | TPL025 | ELIG-PRSN-MAIN-EFF-DATE | Not Applicable | NA | The ELIG-PRSN-MAIN-EFF-DATE must occur on or before the eligible individual's DATE-OF-DEATH as reported in the Eligibility file. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL025-0006 |
| 4634 | TPL026 | ELIG-PRSN-MAIN-END-DATE | The last day of the time span during which the values in all data elements in the ELIG-PRSN-MAIN-EFF-DATE record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Required | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL026-0001 |
| 4635 | TPL026 | ELIG-PRSN-MAIN-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL026-0002 |
| 4636 | TPL026 | ELIG-PRSN-MAIN-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable |
| 4637 | TPL026 | ELIG-PRSN-MAIN-END-DATE | Not Applicable | NA | If the time span is open-ended (i.e., there is no end date), then populate the field with “99991231” (end-of-time). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable |
| 4638 | TPL026 | ELIG-PRSN-MAIN-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable |
| 4639 | TPL026 | ELIG-PRSN-MAIN-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL026-0003 |
| 4640 | TPL026 | ELIG-PRSN-MAIN-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-MAIN record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL026-0004 |
| 4641 | TPL026 | ELIG-PRSN-MAIN-END-DATE | Not Applicable | NA | The ELIG-PRSN-MAIN-END-DATE must occur on or after the ELIG-PRSN-MAIN-EFF-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable |
| 4642 | TPL027 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL027-0001 |
| 4643 | TPL027 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL027-0002 |
| 4644 | TPL028 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | TPL028-0001 |
| 4645 | TPL029 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | TPL00003 | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL029-0003 |
| 4646 | TPL029 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL029-0001 |
| 4647 | TPL030 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL030-0002 |
| 4648 | TPL030 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL030-0001 |
| 4649 | TPL030 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable |
| 4650 | TPL030 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL030-0003 |
| 4651 | TPL031 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL031-0001 |
| 4652 | TPL031 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL031-0002 |
| 4653 | TPL031 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL031-0003 |
| 4654 | TPL032 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL032-0005 |
| 4655 | TPL032 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | For non-SSN states, this field must contain an identification number assigned by the state. The format of the State ID numbers must be supplied to CMS. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL032-0002 |
| 4656 | TPL032 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain temporary MSIS identification number. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS identification number for at least one monthly submission of the TPL File so that T-MSIS can associate the temporary MSIS-IDENTIFICATION-NUM on the TPL file with the temporary MSIS-IDENTIFICATION-NUM and SSN on the Eligibility file. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL032-0003 |
| 4657 | TPL033 | INSURANCE-CARRIER-ID-NUM | The state’s internal identification number of the Third Party Liability (TPL) Insurance carrier. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL033-0001 |
| 4658 | TPL033 | INSURANCE-CARRIER-ID-NUM | Not Applicable | NA | Field is required on all record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable |
| 4659 | TPL033 | INSURANCE-CARRIER-ID-NUM | Not Applicable | NA | Left-fill any unused bytes with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL033-0002 |
| 4660 | TPL034 | INSURANCE-PLAN-ID | The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries’ insurance card. | Conditional | Enter the insurance plan identification number assigned by the state. |
Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL034-0001 |
| 4661 | TPL034 | INSURANCE-PLAN-ID | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL034-0002 |
| 4662 | TPL034 | INSURANCE-PLAN-ID | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL034-0003 |
| 4663 | TPL035 | GROUP-NUM | The group number of the TPL health insurance policy. | Conditional | Left-fill any unused bytes with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL035-0001 |
| 4664 | TPL035 | GROUP-NUM | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL035-0002 |
| 4665 | TPL035 | GROUP-NUM | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL035-0003 |
| 4666 | TPL035 | GROUP-NUM | Not Applicable | NA | If this field is not applicable, leave blank or space-fill | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL035-0004 |
| 4667 | TPL036 | MEMBER-ID | Member identification number as it appears on the card issued by the TPL insurance carrier. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL036-0001 |
| 4668 | TPL036 | MEMBER-ID | Not Applicable | NA | Left-fill any unused bytes with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL036-0002 |
| 4669 | TPL036 | MEMBER-ID | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL036-0003 |
| 4670 | TPL037 | INSURANCE-PLAN-TYPE | Code to classify the type of insurance plan providing TPL coverage. | Conditional | Values must correspond to associated INSURANCE-PLAN-ID. | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL037-0001 |
| 4671 | TPL037 | INSURANCE-PLAN-TYPE | Not Applicable | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL037-0002 |
| 4672 | TPL038 | ANNUAL-DEDUCTIBLE-AMT | Annual amount paid each year by the enrollee in the plan before a health plan benefit begins. | Conditional | The value must consist of digits 0 through 9 only | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL038-0001 |
| 4673 | TPL044 | POLICY-OWNER-FIRST-NAME | The first name of the owner of the insurance policy. For example, the policy owner may be the Medicaid/CHIP beneficiary. | Conditional | Policy owner information is not applicable if the TPL insurance is noted as an "other" type of TPL insurance. If TPL insurance is reported under TYPE-OF-OTHER-THIRD-PARTY-LIABILITY on the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION segment, 8-fill, blank-fill, or space-fill POLICY-OWNER-FIRST-NAME. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL044-0001 |
| 4674 | TPL044 | POLICY-OWNER-FIRST-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL044-0003 |
| 4675 | TPL044 | POLICY-OWNER-FIRST-NAME | Not Applicable | NA | Left-fill any unused bytes with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL044-0004 |
| 4676 | TPL044 | POLICY-OWNER-FIRST-NAME | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL044-0005 |
| 4677 | TPL045 | POLICY-OWNER-LAST-NAME | The last name of the owner of the insurance policy. For example, the policy owner may be the Medicaid/CHIP beneficiary. | Conditional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL045-0001 |
| 4678 | TPL045 | POLICY-OWNER-LAST-NAME | Not Applicable | NA | Left-fill any unused bytes with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL045-0002 |
| 4679 | TPL045 | POLICY-OWNER-LAST-NAME | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL045-0003 |
| 4680 | TPL045 | POLICY-OWNER-LAST-NAME | Not Applicable | NA | If the TPL-HEALTH-INSURANCE-COVERAGE-IND equals '1', this field is required. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL045-0004 |
| 4681 | TPL045 | POLICY-OWNER-LAST-NAME | Not Applicable | NA | Policy owner information is not applicable if the TPL insurance is noted as an "other" type of TPL insurance. If TPL insurance is reported under TYPE-OF-OTHER-THIRD-PARTY-LIABILITY on the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION segment, 8-fill, blank-fill, or space-fill POLICY-OWNER-LAST-NAME. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL045-0005 |
| 4682 | TPL046 | POLICY-OWNER-SSN | The policy owner’s social security number. | Conditional | If known, this field is to be populated with numeric digits. | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL046-0001 |
| 4683 | TPL046 | POLICY-OWNER-SSN | Not Applicable | NA | If the TPL-HEALTH-INSURANCE-COVERAGE-IND equals '1', this field is required. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL046-0002 |
| 4684 | TPL046 | POLICY-OWNER-SSN | Not Applicable | NA | Policy owner information is not applicable if the TPL insurance is noted as an "other" type of TPL insurance. If TPL insurance is reported under TYPE-OF-OTHER-THIRD-PARTY-LIABILITY on the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION segment, 8-fill, blank-fill, or space-fill POLICY-OWNER-SSN. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL046-0003 |
| 4685 | TPL047 | POLICY-OWNER-CODE | This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary. | Conditional | Policy owner information is not applicable if the TPL insurance is noted as an "other" type of TPL insurance. If TPL insurance is reported under TYPE-OF-OTHER-THIRD-PARTY-LIABILITY on the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION segment, 8-fill, blank-fill, or space-fill POLICY-OWNER-CODE. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL047-0001 |
| 4686 | TPL047 | POLICY-OWNER-CODE | Not Applicable | NA | Value must be equal to a valid value. | 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 |
8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL047-0002 |
| 4687 | TPL048 | INSURANCE-COVERAGE-EFF-DATE | The first day of the time span during which the Medicaid enrollee is covered under the policy. This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL048-0001 |
| 4688 | TPL048 | INSURANCE-COVERAGE-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL048-0002 |
| 4689 | TPL048 | INSURANCE-COVERAGE-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL048-0003 |
| 4690 | TPL048 | INSURANCE-COVERAGE-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL048-0004 |
| 4691 | TPL048 | INSURANCE-COVERAGE-EFF-DATE | Not Applicable | NA | The INSURANCE-COVERAGE-EFF-DATE must occur on or before the INSURANCE-COVERAGE-END-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL048-0005 |
| 4692 | TPL048 | INSURANCE-COVERAGE-EFF-DATE | Not Applicable | NA | If the TPL-HEALTH-INSURANCE-COVERAGE-IND equals '1', this field is required. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL048-0006 |
| 4693 | TPL048 | INSURANCE-COVERAGE-EFF-DATE | Not Applicable | NA | The INSURANCE-COVERAGE-EFF-DATE must occur on or before the eligible individual's DATE-OF-DEATH as reported in the Eligibility file. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL048-0007 |
| 4694 | TPL049 | INSURANCE-COVERAGE-END-DATE | The last day of the time span during which the Medicaid enrollee is covered under the policy. | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0001 |
| 4695 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0002 |
| 4696 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0003 |
| 4697 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable |
| 4698 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231). | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0004 |
| 4699 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0005 |
| 4700 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | If the field is not applicable or the TPL insurance is noted under OTHER-THIRD-PARTY-LIABILITY, leave blank or space-fill the field. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0006 |
| 4701 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | If the TPL-HEALTH-INSURANCE-COVERAGE-IND equals '1', this field is required. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0007 |
| 4702 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | The INSURANCE-COVERAGE-END-DATE must occur on or after the INSURANCE-COVERAGE-EFF-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable |
| 4703 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same SUBMITTING-STATE , MSIS-IDENTIFICATION-NUM, INSURANCE-PLAN-ID, GROUP-NUM, and MEMBER-ID. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0008 |
| 4704 | TPL049 | INSURANCE-COVERAGE-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL049-0010 |
| 4705 | TPL050 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL050-0001 |
| 4706 | TPL050 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL050-0002 |
| 4707 | TPL051 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL051-0001 |
| 4708 | TPL052 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | TPL00004 | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL052-0003 |
| 4709 | TPL052 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL052-0001 |
| 4710 | TPL053 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL053-0002 |
| 4711 | TPL053 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL053-0001 |
| 4712 | TPL053 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable |
| 4713 | TPL053 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL053-0003 |
| 4714 | TPL054 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL054-0001 |
| 4715 | TPL054 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL054-0002 |
| 4716 | TPL054 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL054-0003 |
| 4717 | TPL055 | INSURANCE-CARRIER-ID-NUM | The state’s internal identification number of the TPL Insurance carrier. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL055-0001 |
| 4718 | TPL055 | INSURANCE-CARRIER-ID-NUM | Not Applicable | NA | Field is required on all record segments. | Not Applicable | 4/30/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL055-0002 |
| 4719 | TPL055 | INSURANCE-CARRIER-ID-NUM | Not Applicable | NA | Left-fill any unused bytes with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable |
| 4720 | TPL056 | INSURANCE-PLAN-ID | The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries’ insurance card. | Required | Enter the insurance plan identification number assigned by the state. |
Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL056-0001 |
| 4721 | TPL056 | INSURANCE-PLAN-ID | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL056-0002 |
| 4722 | TPL056 | INSURANCE-PLAN-ID | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL056-0003 |
| 4723 | TPL057 | INSURANCE-PLAN-TYPE | Code to classify the entity providing TPL coverage. | Optional | Values must correspond to associated INSURANCE-PLAN-ID. | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL057-0001 |
| 4724 | TPL057 | INSURANCE-PLAN-TYPE | Not Applicable | NA | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 10/10/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL057-0002 |
| 4725 | TPL058 | COVERAGE-TYPE | Code indicating the level of coverage being provided under this policy for the insured by the TPL carrier. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL058-0001 |
| 4726 | TPL059 | INSURANCE-CATEGORIES-EFF-DATE | The first day of the time span during which the values in all data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL059-0001 |
| 4727 | TPL059 | INSURANCE-CATEGORIES-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL059-0002 |
| 4728 | TPL059 | INSURANCE-CATEGORIES-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL059-0003 |
| 4729 | TPL059 | INSURANCE-CATEGORIES-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable |
| 4730 | TPL059 | INSURANCE-CATEGORIES-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL059-0004 |
| 4731 | TPL059 | INSURANCE-CATEGORIES-EFF-DATE | Not Applicable | NA | The INSURANCE-CATEGORIES-EFF-DATE must occur on or before the INSURANCE-CATEGORIES-EFF-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL059-0005 |
| 4732 | TPL060 | INSURANCE-CATEGORIES-END-DATE | The last day of the time span during which the values in all data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0001 |
| 4733 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0002 |
| 4734 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0003 |
| 4735 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231). | Not Applicable | 4/30/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0004 |
| 4736 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable |
| 4737 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | The INSURANCE-CATEGORIES-END-DATE must occur on or after the INSURANCE-CATEGORIES-END-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable |
| 4738 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0005 |
| 4739 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | If the field is not applicable or the TPL insurance is noted under OTHER-THIRD-PARTY-LIABILITY, leave blank or space-fill the field. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0006 |
| 4740 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | If the TPL-HEALTH-INSURANCE-COVERAGE-IND equals '1', this field is required. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0007 |
| 4741 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0009 |
| 4742 | TPL060 | INSURANCE-CATEGORIES-END-DATE | Not Applicable | NA | The segment must have both a matching, active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN record and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO record and the INSURANCE-CATEGORIES-EFF-DATE must be on or before ELIG-PRSN-MAIN-EFF-DATE and INSURANCE-COVERAGE-EFF-DATE, and INSURANCE-CATEGORIES-END-DATE must be on or after ELIG-PRSN-MAIN-END-DATE and INSURANCE-COVERAGE-END-DATE. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL060-0010 |
| 4743 | TPL061 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL061-0001 |
| 4744 | TPL061 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL061-0002 |
| 4745 | TPL062 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | TPL062-0001 |
| 4746 | TPL063 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | TPL00005 | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL063-0003 |
| 4747 | TPL063 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL063-0001 |
| 4748 | TPL064 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL064-0002 |
| 4749 | TPL064 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL064-0001 |
| 4750 | TPL064 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable |
| 4751 | TPL064 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL064-0003 |
| 4752 | TPL065 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL065-0001 |
| 4753 | TPL065 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL065-0002 |
| 4754 | TPL065 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL065-0003 |
| 4755 | TPL066 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | MSIS-IDENTIFICATION-NUM must be reported | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL066-0005 |
| 4756 | TPL066 | MSIS-IDENTIFICATION-NUM | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual and any claims submitted to the system. | Required | The Medicaid/CHIP enrollee’s MSIS-IDENTIFICATION-NUM must match the MSIS-IDENTIFICATION-NUM in the T-MSIS Eligibility file and T-MSIS data repository. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL066-0001 |
| 4757 | TPL066 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For non-SSN states, this field must contain an identification number assigned by the state. The format of the State ID numbers must be supplied to CMS. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL066-0002 |
| 4758 | TPL066 | MSIS-IDENTIFICATION-NUM | Not Applicable | NA | For SSN states, this field must contain the eligible individual's Social Security Number. If the SSN is unknown and a temporary number is assigned, this field will contain temporary MSIS identification number. When the social security number becomes known, the MSIS-IDENTIFICATION-NUM field should continue to be populated with the temporary MSIS identification number for at least one monthly submission of the TPL File so that T-MSIS can associate the temporary MSIS-IDENTIFICATION-NUM on the TPL file with the temporary MSIS-IDENTIFICATION-NUM and SSN on the Eligibility file. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL066-0003 |
| 4759 | TPL067 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed INSURANCE-TYPE-PLAN. | Conditional | Required | Not Applicable | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL067-0001 |
| 4760 | TPL067 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Not Applicable | NA | Value must be equal to a valid value. | 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 |
8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL067-0002 |
| 4761 | TPL068 | OTHER-TPL-EFF-DATE | The first day of the time span during which the values in all data elements in the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL068-0001 |
| 4762 | TPL068 | OTHER-TPL-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL068-0002 |
| 4763 | TPL068 | OTHER-TPL-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL068-0003 |
| 4764 | TPL068 | OTHER-TPL-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable |
| 4765 | TPL068 | OTHER-TPL-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL068-0004 |
| 4766 | TPL068 | OTHER-TPL-EFF-DATE | Not Applicable | NA | The OTHER-TPL-EFF-DATE must occur on or before the OTHER-TPL-EFF-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL068-0005 |
| 4767 | TPL068 | OTHER-TPL-EFF-DATE | Not Applicable | NA | If the TPL-OTHER-COVERAGE-IND equals '1', this field is required. | Not Applicable | 4/30/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL068-0006 |
| 4768 | TPL068 | OTHER-TPL-EFF-DATE | Not Applicable | NA | The OTHER-TPL-EFF-DATE must occur on or before the eligible individual's DATE-OF-DEATH as reported in the Eligibility file. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL068-0007 |
| 4769 | TPL069 | OTHER-TPL-END-DATE | The last day of the time span during which the values in all data elements in the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created.) | Conditional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0001 |
| 4770 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0002 |
| 4771 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0003 |
| 4772 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231). | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0004 |
| 4773 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable |
| 4774 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | The OTHER-TPL-END-DATE must occur on or after the OTHER-TPL-EFF-DATE | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable |
| 4775 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0005 |
| 4776 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | If the field is not applicable or the TPL-OTHER-COVERAGE-IND = 0, 8-fill, leave blank, or space-fill the field. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0006 |
| 4777 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | If the TPL-OTHER-COVERAGE-IND equals '1', this field is required. | Not Applicable | 4/30/2013 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0007 |
| 4778 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same SUBMITTING-STATE , MSIS-IDENTIFICATION-NUM, and TYPE-OF-OTHER-THIRD-PARTY-LIABILITY. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0008 |
| 4779 | TPL069 | OTHER-TPL-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL069-0010 |
| 4780 | TPL070 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL070-0001 |
| 4781 | TPL070 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL070-0002 |
| 4782 | TPL071 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | TPL071-0001 |
| 4783 | TPL072 | RECORD-ID | An identifier assigned to each record segment. The first 3 characters identify the subject area. The last 5 bytes are an integer with leading zeros. For example, the RECORD-ID for the PRIMARY DEMOGRAPHICS – ELIGIBILITY record segment is ELG00002. | Required | Value must be equal to a valid value. | TPL00006 | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION- TPL00006 | TPL072-0003 |
| 4784 | TPL072 | RECORD-ID | Not Applicable | NA | Must be populated on every record segment. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL072-0001 |
| 4785 | TPL073 | SUBMITTING-STATE | The ANSI numeric state code for the U.S. state, territory, or the District of Columbia that has submitted the data. | Required | Value must be equal to a valid value. |
http://www.census.gov/geo/reference/ansi_statetables.html | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL073-0002 |
| 4786 | TPL073 | SUBMITTING-STATE | Not Applicable | NA | Must be populated on every record. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL073-0001 |
| 4787 | TPL073 | SUBMITTING-STATE | Not Applicable | NA | Value must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable |
| 4788 | TPL073 | SUBMITTING-STATE | Not Applicable | NA | Value must be the same on all record segments. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL073-0003 |
| 4789 | TPL074 | RECORD-NUMBER | A sequential number assigned by the submitter to identify each record segment row in the submission file. The RECORD-NUMBER, in conjunction with the RECORD-ID, uniquely identifies a single record within the submission file. | Required | Must be populated on every record | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL074-0001 |
| 4790 | TPL074 | RECORD-NUMBER | Not Applicable | NA | Must be numeric | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL074-0002 |
| 4791 | TPL074 | RECORD-NUMBER | Not Applicable | NA | RECORD-ID/RECORD-NUMBER combinations should be unique within a state's submission. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL074-0003 |
| 4792 | TPL075 | INSURANCE-CARRIER-ID-NUM | The state’s internal identification number of the TPL Insurance carrier. | Required | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL075-0001 |
| 4793 | TPL075 | INSURANCE-CARRIER-ID-NUM | Not Applicable | NA | Field is required on all record segments. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable |
| 4794 | TPL075 | INSURANCE-CARRIER-ID-NUM | Not Applicable | NA | Left-fill any unused bytes with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL075-0002 |
| 4795 | TPL076 | TPL-ENTITY-ADDR-TYPE | A code to distinguish various addresses that a TPL entity may have. The state should report whatever types of address they have. | Optional | This data element must be populated on every record within the TPL-ENTITY-CONTACT-INFORMATION record segment. | Not Applicable | 11/3/2015 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL076-0001 |
| 4796 | TPL076 | TPL-ENTITY-ADDR-TYPE | Not Applicable | NA | Value must be equal to a valid value. | 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 |
8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL076-0002 |
| 4797 | TPL077 | INSURANCE-CARRIER-ADDR-LN1 | The street address, including the street name, street number, and room/suite number or letter, for the location for the TPL Insurance carrier. | Optional | INSURANCE-CARRIER-ADDR-LN1 is required. INSURANCE-CARRIER-ADDR-LN2 and INSURANCE-CARRIER-ADDR-LN3 can be blank. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL077-0001 |
| 4798 | TPL077 | INSURANCE-CARRIER-ADDR-LN1 | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL077-0002 |
| 4799 | TPL077 | INSURANCE-CARRIER-ADDR-LN1 | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 4/30/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL077-0003 |
| 4800 | TPL078 | INSURANCE-CARRIER-ADDR-LN2 | The street address, including the street name, street number, and room/suite number or letter, for the location for the TPL Insurance carrier. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL078-0001 |
| 4801 | TPL079 | INSURANCE-CARRIER-ADDR-LN3 | The street address, including the street name, street number, and room/suite number or letter, for the location for the TPL Insurance carrier. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL079-0001 |
| 4802 | TPL080 | INSURANCE-CARRIER-CITY | The city of the TPL Insurance carrier. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL080-0001 |
| 4803 | TPL081 | INSURANCE-CARRIER-STATE | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the TPL Insurance carrier. | Optional | Value must be equal to a valid value. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL081-0001 |
| 4804 | TPL082 | INSURANCE-CARRIER-ZIP-CODE | The Zip Code for the location being captured on the TPL-ENTITY-CONTACT-INFORMATION record. |
NA | If the field is reported, the first 5 bytes (i.e., the 5-digit zip code) are required | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL082-0002 |
| 4805 | TPL082 | INSURANCE-CARRIER-ZIP-CODE | Not Applicable | NA | The value must consist of digits 0 through 9 only. | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL082-0003 |
| 4806 | TPL082 | INSURANCE-CARRIER-ZIP-CODE | Not Applicable | NA | If the field is reported and the four-digit extension is available, that may be filled in using the last four bytes. Otherwise, if the last 4 digits are not populated or used, then the 4-digit extended zip code should be recorded as “0000”. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL082-0004 |
| 4807 | TPL082 | INSURANCE-CARRIER-ZIP-CODE | Not Applicable | NA | If the entire zip code field is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL082-0005 |
| 4808 | TPL083 | INSURANCE-CARRIER-PHONE-NUM | The telephone number of the TPL Insurance carrier. | Optional | Enter numeric characters only (i.e., do not include parentheses, dashes, periods, spaces, etc.) | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL083-0001 |
| 4809 | TPL083 | INSURANCE-CARRIER-PHONE-NUM | Not Applicable | NA | The value must consist of digits 0 through 9 only. | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL083-0002 |
| 4810 | TPL083 | INSURANCE-CARRIER-PHONE-NUM | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL083-0003 |
| 4811 | TPL084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | The first day of the time span during which the values in all data elements in the TPL-ENTITY-CONTACT-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). This date field is necessary when defining a unique row in a database table. |
Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL084-0001 |
| 4812 | TPL084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL084-0002 |
| 4813 | TPL084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Value must be a valid date. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL084-0003 |
| 4814 | TPL084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | Not Applicable | NA | For parent and child file segments, the effective date of a child record segment must occur before or be concurrent with the effective date of the parent file segment, where submitting state and file segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable |
| 4815 | TPL084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-ENTITY-CONTACT-INFORMATION record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL084-0004 |
| 4816 | TPL084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | Not Applicable | NA | The TPL-ENTITY-CONTACT-INFO-EFF-DATE must occur on or before the TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL084-0005 |
| 4817 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | The last day of the time span during which the values in all data elements in the TPL-ENTITY-CONTACT-INFORMATION record segment are in effect (i.e., the values accurately reflect reality as it is understood to be at the time the record is created). | Optional | Date format is CCYYMMDD (National Data Standard). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL085-0001 |
| 4818 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | Value must be numeric. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL085-0002 |
| 4819 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | Value must be a valid date | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL085-0003 |
| 4820 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | If there is no end date (i.e., the record is good into the indefinite future) use the “end-of-time” date (99991231). | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL085-0004 |
| 4821 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | The TPL-ENTITY-CONTACT-INFO-END-DATE must occur on or after the TPL-ENTITY-CONTACT-INFO-EFF-DATE | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable |
| 4822 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | If a complete, valid end date is not available or is unknown,leave blank, or space-fill | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable |
| 4823 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | Whenever the value in one or more of the data elements in the TPL-ENTITY-CONTACT-INFORMATION record segment changes, a new record segment must be created. | Not Applicable | 2/25/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL085-0005 |
| 4824 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | Overlapping coverage not allowed for same SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM and TPL-ENTITY-ADDR-TYPE. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL085-0006 |
| 4825 | TPL085 | TPL-ENTITY-CONTACT-INFO-END-DATE | Not Applicable | NA | For parent and child record segments, the end date of a child record segment must occur before or be concurrent with the end date of the parent record segment, where submitting state and record segment-specific identifying number match one another in both record segments. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL085-0008 |
| 4826 | TPL086 | STATE-NOTATION | A free text field for the submitting state to enter whatever information it chooses. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL086-0001 |
| 4827 | TPL086 | STATE-NOTATION | Not Applicable | NA | For pipe-delimited files, states can populate the STATE-NOTATION field with “n/a,” “n.a.” or leave the field blank (i.e., submitted as "pipe pipe" with nothing in between (||) ) when not using the field to record specific comments. For fixed-length files, states should space-fill the STATE-NOTATION field when not using the field to record specific comments, and right-pad the field with spaces when the field does contain verbiage. |
Not Applicable | 9/23/2015 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL086-0002 |
| 4828 | TPL087 | FILLER | Not Applicable | NA | For pipe-delimited files, FILLER that is shown at the end of each record layout is applicable only to fixed-length files and therefore should be ignored in pipe-delimited files. For fixed-length files, FILLER that is shown at the end of each record layout should be space-filled in fixed-length files. |
Not Applicable | 9/23/2015 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL087-0001 |
| 4829 | TPL088 | SEQUENCE-NUMBER | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | Required | Field is required on all 'C', 'U', and 'R' SUBMISSION-TRANSACTION-TYPE record files. | Not Applicable | 8/7/2017 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL088-0001 |
| 4830 | TPL088 | SEQUENCE-NUMBER | Not Applicable | NA | Must be numeric and > 0 | Not Applicable | 10/10/2013 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 | TPL088-0002 |
| 4831 | TPL089 | COVERAGE-TYPE | Code indicating the level of coverage being provided under this policy for the insured by the TPL carrier. | Conditional | Value must be equal to a valid value. | See Appendix A for listing of valid values. | 11/3/2015 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | TPL089-0001 |
| 4832 | TPL090 | INSURANCE-CARRIER-NAIC-CODE | The National Association of Insurance Commissioners (NAIC) code of the TPL Insurance carrier. | Optional | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL090-0001 |
| 4833 | TPL091 | INSURANCE-CARRIER-NAME | The name of the TPL Insurance carrier. | Optional | Field is required on all records. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL091-0001 |
| 4834 | TPL091 | INSURANCE-CARRIER-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL091-0002 |
| 4835 | TPL091 | INSURANCE-CARRIER-NAME | Not Applicable | NA | If the field value is missing, keep the default value of spaces. | Not Applicable | 10/10/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL091-0003 |
| 4836 | TPL092 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | The NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE distinguishes “controlling” health plan identifiers (CHPIDs), “subhealth” health plan identifiers (SHPIDs), and other entity identifiers (OEIDs) from one another. (See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL092-0001 |
| 4837 | TPL092 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | NA | Value must be in the set of valid values | 1 Controlling Health Plan (CHP) ID 2 Subhealth Plan (SHP) ID 3 Other Entity Identifier (OEID) |
10/10/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL092-0003 |
| 4838 | TPL092 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | NA | If the type HEALTH-CARE-ENTITY-ID-TYPE is unknown, populate the field with an "8", "9", or space | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL092-0004 |
| 4839 | TPL093 | NATIONAL-HEALTH-CARE-ENTITY-ID | The national identifier of the health care entity (controlling health plan, subhealth plan, or other entity) at the most granular sub-health plan level of the Medicaid or CHIP health plan in which an individual is enrolled. (See 45 CFR 162 Subpart E. http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf ) | NA | Implementation of 45 CFR 162 Subpart E regarding the requirement for large and small health plans to obtain national health plan identifiers was delayed indefinitely as of 10/31/2014. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL093-0001 |
| 4840 | TPL093 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | This field is required for all eligible persons enrolled in a health plan. If the eligible person is not enrolled in a health plan, fill the field with spaces. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL093-0003 |
| 4841 | TPL093 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). | Not Applicable | 10/10/2013 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL093-0004 |
| 4842 | TPL093 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | NA | National identifiers in the TPL file must match either a controlling health plan (CHP) identifier or subhealth plan (SHP) identifier in the health plan subject area. | Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL093-0005 |
| 4843 | TPL094 | NATIONAL-HEALTH-CARE-ENTITY-NAME | The legal name of the health care entity identified by the corresponding value in the NATIONAL-HEALTH-CARE-ENTITY-ID field. | NA | Use the descriptive name assigned by the state as it exists in the state’s MMIS. | Not Applicable | 11/3/2015 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL094-0001 |
| 4844 | TPL094 | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | NA | The field can contain any alphanumeric characters, digits or symbols except the "pipe" (|). |
Not Applicable | 8/7/2017 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | TPL094-0002 |
| End of Record |
Sheet 3: Rec Segment Keys & Constraints
| Record Segment Keys and Constraints | |||||
| (a) = Data element is part of the record segment key, but is not considered when evaluating the date constraints | |||||
| File Name | File Segment (with Record-ID) | Key Field Identifier | Data Element Name | Intra-Record Segment Constraints | Inter-Record Segment Constraints |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TYPE-OF-HOSPITAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMISSION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DRG-DESCRIPTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE-FLAG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-7 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-7 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-7 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-8 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-8 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-8 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-9 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-9 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-9 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-11 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-11 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-11 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-12 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-12 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-12 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-RELATED-GROUP | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-RELATED-GROUP-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMISSION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMISSION-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DISCHARGE-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DISCHARGE-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TYPE-OF-BILL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ALLOWED-CHARGE-SRC | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | NON-COV-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | NON-COV-CHARGES | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICAID-COV-INPATIENT-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-CARE-ACQUIRED-CONDITION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BIRTH-WEIGHT-GRAMS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DRG-OUTLIER-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DRG-REL-WEIGHT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OUTLIER-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OUTLIER-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PATIENT-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BMI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SPLIT-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICAID-AMOUNT-PAID-DSH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OPERATING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | REVENUE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | REVENUE-CHARGE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | BILLING-UNIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | OPERATING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | PROV-FACILITY-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | HCPCS-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | NDC-UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | NDC-QUANTITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE-FLAG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMISSION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMISSION-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DISCHARGE-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DISCHARGE-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TYPE-OF-BILL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NON-COV-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NON-COV-CHARGES | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICAID-COV-INPATIENT-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-CARE-ACQUIRED-CONDITION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PATIENT-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BMI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | LTC-RCP-LIAB-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DAILY-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ICF-IID-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | LEAVE-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NURSING-FACILITY-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SPLIT-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | REVENUE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | REVENUE-CHARGE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | BILLING-UNIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | PROV-FACILITY-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | NDC-UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | NDC-QUANTITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | HCPCS-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TYPE-OF-BILL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-CARE-ACQUIRED-CONDITION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PLACE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BMI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DAILY-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DATE-CAPITATED-AMOUNT-REQUESTED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CAPITATED-PAYMENT-AMT-REQUESTED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | REVENUE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-FLAG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | HCBS-SERVICE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | HCBS-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-DESIGNATION-SYSTEM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-QUAD-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-SURFACE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-ADDR-LN1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-ADDR-LN2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-CITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-ZIP-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-ADDR-LN1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-ADDR-LN2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-CITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-ZIP-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | HCPCS-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | NDC-UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | NDC-QUANTITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DATE-PRESCRIBED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIPTION-FILL-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | COMPOUND-DRUG-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | HCBS-SERVICE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | HCBS-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DAYS-SUPPLY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | NEW-REFILL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | BRAND-GENERIC-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DISPENSE-FEE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | PRESCRIPTION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DRUG-UTILIZATION-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DTL-METRIC-DEC-QTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | COMPOUND-DOSAGE-FORM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | REBATE-ELIGIBLE-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | ELIGIBLE-FIRST-NAME | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | ELIGIBLE-LAST-NAME | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | SEX | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | DATE-OF-BIRTH | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | DATE-OF-DEATH | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | (a) | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MARITAL-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MARITAL-STATUS-OTHER-EXPLANATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | SSN | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | SSN-VERIFICATION-FLAG | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | INCOME-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | VETERAN-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | CITIZENSHIP-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | CITIZENSHIP-VERIFICATION-FLAG | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | IMMIGRATION-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | IMMIGRATION-VERIFICATION-FLAG | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | PRIMARY-LANGUAGE-ENGL-PROF-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | PRIMARY-LANGUAGE-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | HOUSEHOLD-SIZE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | PREGNANCY-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MEDICARE-HIC-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | CHIP-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | (a) | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | 3 | ADDR-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-LN1 | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-LN2 | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-LN3 | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-CITY | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ZIP-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-COUNTY-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-PHONE-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | TYPE-OF-LIVING-ARRANGEMENT | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | (a) | ELIGIBLE-ADDR-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE MSIS-IDENTIFICATION-NUM, and ADDR-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE MSIS-IDENTIFICATION-NUM, and ADDR-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 3 | MSIS-CASE-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | DUAL-ELIGIBLE-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 4 | PRIMARY-ELIGIBILITY-GROUP-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | ELIGIBILITY-GROUP | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | LEVEL-OF-CARE-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSDI-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSI-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSI-STATE-SUPPLEMENT-STATUS-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSI-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | STATE-SPEC-ELIG-GROUP | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | CONCEPTION-TO-BIRTH-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | ELIGIBILITY-CHANGE-REASON | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | RESTRICTED-BENEFITS-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | TANF-CASH-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 5 | ELIGIBILITY-DETERMINANT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, and MSIS-CASE-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | ELIGIBILITY-DETERMINANT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, and MSIS-CASE-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 3 | HEALTH-HOME-SPA-NAME | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 4 | HEALTH-HOME-ENTITY-NAME | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | (a) | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, and HEALTH-HOME-ENTITY-NAME | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, and HEALTH-HOME-ENTITY-NAME | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | RECORD-ID | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 3 | HEALTH-HOME-SPA-NAME | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 4 | HEALTH-HOME-ENTITY-NAME | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 5 | HEALTH-HOME-PROV-NUM | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | (a) | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, HEALTH-HOME-ENTITY-NAME, and HEALTH-HOME-PROV-NUM | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | HEALTH-HOME-SPA-PROVIDER-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, HEALTH-HOME-ENTITY-NAME, and HEALTH-HOME-PROV-NUM | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | FILLER | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 3 | HEALTH-HOME-CHRONIC-CONDITION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 4 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | (a) | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-CHRONIC-CONDITION, and HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-CHRONIC-CONDITION, and HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 3 | LOCKIN-PROV-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 4 | LOCKED-IN-SRVCS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | (a) | LOCKIN-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LOCKIN-PROV-NUM, and LOCKED-IN-SRVCS | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | LOCKIN-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LOCKIN-PROV-NUM, and LOCKED-IN-SRVCS | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-LIVES-WITH-FAMILY | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-QUALIFIED-INSTITUTION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-QUALIFIED-RESIDENCE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-REASON-PARTICIPATION-ENDED | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-REINSTITUTIONALIZED-REASON | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | (a) | MFP-ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | 3 | STATE-PLAN-OPTION-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | (a) | STATE-PLAN-OPTION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and STATE-PLAN-OPTION-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | STATE-PLAN-OPTION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and STATE-PLAN-OPTION-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | 3 | WAIVER-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | WAIVER-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | (a) | WAIVER-ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and WAIVER-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | WAIVER-ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and WAIVER-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 3 | LTSS-LEVEL-CARE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 4 | LTSS-PROV-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | (a) | LTSS-ELIGIBILITY-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LTSS-LEVEL-CARE, and LTSS-PROV-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | LTSS-ELIGIBILITY-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LTSS-LEVEL-CARE, and LTSS-PROV-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | 3 | MANAGED-CARE-PLAN-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | MANAGED-CARE-PLAN-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | (a) | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and MANAGED-CARE-PLAN-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and MANAGED-CARE-PLAN-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | 3 | ETHNICITY-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | (a) | ETHNICITY-DECLARATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ETHNICITY-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | ETHNICITY-DECLARATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ETHNICITY-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 3 | RACE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 4 | RACE-OTHER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | AMERICAN-INDIAN/ALASKAN-NATIVE-INDICATOR | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | (a) | RACE-DECLARATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, RACE, and RACE-OTHER | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | RACE-DECLARATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, RACE, and RACE-OTHER | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | 3 | DISABILITY-TYPE-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | (a) | DISABILITY-TYPE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and DISABILITY-TYPE-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | DISABILITY-TYPE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and DISABILITY-TYPE-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | 3 | 1115A-DEMONSTRATION-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | (a) | 1115A-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and 1115A-DEMONSTRATION-IND | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | 1115A-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and 1115A-DEMONSTRATION-IND | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | 3 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | (a) | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | 3 | ENROLLMENT-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | (a) | ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ENROLLMENT-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ENROLLMENT-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | 2 | STATE-PLAN-ID-NUM | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-CONTRACT-EFF-DATE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-NAME | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-PROGRAM | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-PLAN-TYPE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | REIMBURSEMENT-ARRANGEMENT | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-PROFIT-STATUS | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | CORE-BASED-STATISTICAL-AREA-CODE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | PERCENT-BUSINESS | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-SERVICE-AREA | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | (a) | MANAGED-CARE-MAIN-REC-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and STATE-PLAN-ID-NUM | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-MAIN-REC-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and STATE-PLAN-ID-NUM | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 2 | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 3 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 4 | MANAGED-CARE-LOCATION-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | (a) | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, MANAGED-CARE-LOCATION-ID, and MANAGED-CARE-ADDR-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, MANAGED-CARE-LOCATION-ID, and MANAGED-CARE-ADDR-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 5 | MANAGED-CARE-ADDR-TYPE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ADDR-LN1 | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ADDR-LN2 | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ADDR-LN3 | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-CITY | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ZIP-CODE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-COUNTY | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-TELEPHONE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-EMAIL | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-FAX-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | 3 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | (a) | MANAGED-CARE-SERVICE-AREA-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-SERVICE-AREA-NAME | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | MANAGED-CARE-SERVICE-AREA-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-SERVICE-AREA-NAME | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 3 | OPERATING-AUTHORITY | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 4 | WAIVER-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | (a) | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, OPERATING-AUTHORITY, and WAIVER-ID | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | MANAGED-CARE-OP-AUTHORITY-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, OPERATING-AUTHORITY, and WAIVER-ID | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | 3 | MANAGED-CARE-PLAN-POP | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | (a) | MANAGED-CARE-PLAN-POP-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-PLAN-POP | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | MANAGED-CARE-PLAN-POP-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-PLAN-POP | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | 3 | ACCREDITATION-ORGANIZATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | (a) | DATE-ACCREDITATION-ACHIEVED | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, ACCREDITATION-ORGANIZATION | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | DATE-ACCREDITATION-END | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, ACCREDITATION-ORGANIZATION | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 3 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 4 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | (a) | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, NATIONAL-HEALTH-CARE-ENTITY-ID, and NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, NATIONAL-HEALTH-CARE-ENTITY-ID, and NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | RECORD-ID | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 3 | CHPID | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 4 | SHPID | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | (a) | CHPID-SHPID-RELATIONSHIP-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, CHPID, and SHPID | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | CHPID-SHPID-RELATIONSHIP-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, CHPID, and SHPID | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | FILLER | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | (a) | PROV-ATTRIBUTES-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-ATTRIBUTES-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-DOING-BUSINESS-AS-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-LEGAL-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-ORGANIZATION-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-TAX-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | FACILITY-GROUP-INDIVIDUAL-CODE | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | TEACHING-IND | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-FIRST-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-MIDDLE-INITIAL | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-LAST-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | SEX | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | OWNERSHIP-CODE | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-PROFIT-STATUS | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | DATE-OF-BIRTH | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | DATE-OF-DEATH | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | ACCEPTING-NEW-PATIENTS-IND | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 2 | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 3 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 4 | PROV-LOCATION-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | (a) | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 5 | ADDR-TYPE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-LN1 | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-LN2 | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-LN3 | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-CITY | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-ZIP-CODE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-TELEPHONE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-EMAIL | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-FAX-NUM | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-BORDER-STATE-IND | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-COUNTY | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 3 | PROV-LOCATION-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | (a) | PROV-LICENSE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, LICENSE-TYPE, and LICENSE-ISSUING-ENTITY-ID | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | PROV-LICENSE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, LICENSE-TYPE, and LICENSE-ISSUING-ENTITY-ID | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 4 | LICENSE-TYPE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 5 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 6 | LICENSE-OR-ACCREDITATION-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | FILLER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 3 | PROV-LOCATION-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 4 | PROV-IDENTIFIER-TYPE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 5 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | (a) | PROV-IDENTIFIER-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, PROV-IDENTIFIER-TYPE, PROV-IDENTIFIER-ISSUING-ENTITY-ID, and PROV-IDENTIFIER | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | PROV-IDENTIFIER-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, PROV-IDENTIFIER-TYPE, PROV-IDENTIFIER-ISSUING-ENTITY-ID, and PROV-IDENTIFIER | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 6 | PROV-IDENTIFIER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | FILLER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 3 | PROV-CLASSIFICATION-TYPE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 4 | PROV-CLASSIFICATION-CODE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | (a) | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-CLASSIFICATION-TYPE, PROV-CLASSIFICATION-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | PROV-TAXONOMY-CLASSIFICATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-CLASSIFICATION-TYPE, PROV-CLASSIFICATION-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | (a) | PROV-MEDICAID-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-MEDICAID-ENROLLMENT-STATUS-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | PROV-MEDICAID-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-MEDICAID-ENROLLMENT-STATUS-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | 3 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | STATE-PLAN-ENROLLMENT | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | PROV-ENROLLMENT-METHOD | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | APPL-DATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | 3 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | (a) | PROV-AFFILIATED-GROUP-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | PROV-AFFILIATED-GROUP-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 3 | AFFILIATED-PROGRAM-TYPE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 4 | AFFILIATED-PROGRAM-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | (a) | PROV-AFFILIATED-PROGRAM-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, AFFILIATED-PROGRAM-TYPE, and AFFILIATED-PROGRAM-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | PROV-AFFILIATED-PROGRAM-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, AFFILIATED-PROGRAM-TYPE, and AFFILIATED-PROGRAM-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 3 | PROV-LOCATION-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | (a) | BED-TYPE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, and BED-TYPE-CODE | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | BED-TYPE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, and BED-TYPE-CODE | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 4 | BED-TYPE-CODE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | BED-COUNT | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | FILLER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | TPL-HEALTH-INSURANCE-COVERAGE-IND | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | TPL-OTHER-COVERAGE-IND | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIGIBLE-FIRST-NAME | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIGIBLE-LAST-NAME | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | (a) | ELIG-PRSN-MAIN-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIG-PRSN-MAIN-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 3 | INSURANCE-CARRIER-ID-NUM | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 4 | INSURANCE-PLAN-ID | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 5 | GROUP-NUM | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 6 | MEMBER-ID | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | INSURANCE-PLAN-TYPE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | COVERAGE-TYPE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | ANNUAL-DEDUCTIBLE-AMT | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-FIRST-NAME | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-LAST-NAME | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-SSN | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-CODE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | (a) | INSURANCE-COVERAGE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, GROUP-NUM, MEMBER-ID, and COVERAGE-TYPE | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | INSURANCE-COVERAGE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, GROUP-NUM, MEMBER-ID, and COVERAGE-TYPE | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | FILLER | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | RECORD-ID | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 2 | INSURANCE-CARRIER-ID-NUM | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 3 | INSURANCE-PLAN-ID | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | INSURANCE-PLAN-TYPE | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 4 | COVERAGE-TYPE | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | (a) | INSURANCE-CATEGORIES-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, and COVERAGE-TYPE | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | INSURANCE-CATEGORIES-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, and COVERAGE-TYPE | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | FILLER | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | RECORD-ID | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | 3 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | (a) | OTHER-TPL-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | OTHER-TPL-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | FILLER | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | 2 | INSURANCE-CARRIER-ID-NUM | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | 3 | TPL-ENTITY-ADDR-TYPE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ADDR-LN1 | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ADDR-LN2 | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ADDR-LN3 | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-CITY | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-STATE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ZIP-CODE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-PHONE-NUM | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | (a) | TPL-ENTITY-CONTACT-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, and TPL-ENTITY-ADDR-TYPE | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | TPL-ENTITY-CONTACT-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, and TPL-ENTITY-ADDR-TYPE | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-NAIC-CODE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-NAME | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| End of Record |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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